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 Harvoni 90-400 mg for a duration of 24 weeks for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment.  In this patients case, the provided APRI score is not consistent with advanced fibrosis or cirrhosis.  Per the records, the patient does not have cirrhosis, and no other reason for urgent re-treatment compatible with the high-urgency group in the guidelines is provided.  The guidelines do not support treatment at this time. Final Result: The reviewer determined that the requested medication regimen 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the superior efficacy of the patients initial three-dimensional breast tomosynthesis.  However, the follow-up three-dimensional breast tomosynthesis was not likely to have been of greater benefit than other modalities.  Breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the two-dimensional images on the initial screening exam was of greater benefit to the patient than had the exam been done with the two-dimensional technique only.  There is a lack of support for the addition of bilateral tomosynthesis as part of the follow-up diagnostic study as it would not have provided additional information not already available.  Final Result: Two reviewers determined that a portion 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 partially overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology 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

Standard Review :The parent of a transgender male enrollee has requested authorization and coverage for a consultation with a plastic surgeon regarding bilateral mastectomy for male chest reconstruction. The Health Plan has denied this request indicating that the requested service is not medically necessary for evaluation of the enrollees gender dysphoria. 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. Nature of Statutory Criteria/Case Summary: Based on the documentation provided, the patient presents with gender dysphoria and is in the process of transitioning from female to male.  Based on the patients gender dysphoria and identification as a male, a normal appearing male chest is the goal. A resolution from the American Psychiatric Association (APA) presented its report in June 2012. This resolution concluded that the medical research demonstrated the effectiveness and necessity of mental health care, hormone therapy and sexual reassignment surgery for individuals diagnosed with gender dysphoria or gender identity disorder.  The surgical concept of treating breasts in individuals undergoing female to male reassignment surgery is well established and documented within the community of plastic surgeons.  Each patient must be reviewed on a case-by-case basis to determine the medical appropriateness of the treatment. In this patients case, he is an adolescent and is only seeking a surgical consultation at this point in time. A plastic surgeon is qualified to provide an evaluation and determination as to the ultimate suitability for the surgical transition. Thus, it is medically reasonable and appropriate to proceed with a surgical consultation at this time. As such, the requested consultation with a plastic surgeon regarding bilateral mastectomy for male chest reconstruction is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis for treatment of the enrollees back pain. Findings:  The physician reviewers found that although the current data do not provide a consistent recommendation for thoracic radiofrequency ablation, this patient has been through a number of conservative measures including medical supplementation and long-term narcotic use. The records document chronic pain status post thoracic wedge compression fracture. The patient has been treated with a number of interventions including medical bone building regimen. Due to the physiological changes created to the posterior columns, she has developed pain to the facets of the upper thoracic spine. Given the persistence of this patients condition despite treatment with conservative measures, the radiofrequency neurolysis was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in anesthesiology with sub-specialty certification in pain 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: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee requested continued home intravenous immunoglobulin (IVIG) infusions twice per month for medical treatment of his myasthenia gravis. Findings:  The physician reviewer found that his records do not indicate that he has been treated with standard immunotherapy including oral steroids, azathioprine, or mycophenolate mofetil. In this case specifically, it is unclear from the records whether he is in a long-term remission, which may occur after thymectomy. In order to treat his myasthenia gravis exacerbation and transition him to a more standard therapy, treatment with IVIG twice per month for 90 days is appropriate. For these reasons, a portion of the requested IVIG therapy is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) bone density scan for evaluation of her  osteopenia.  Findings:  The physician reviewer found that the T scores  were consistent with mild osteopenia that can occur in patients who have been on treatment with Depo-Provera. These changes resolve without specific treatment other than discontinuing the Depo-Provera therapy. The patient was treated by discontinuance of the Depo-Provera, followed by estrogen supplements and subsequent oral combination contraceptives. The DEXA scans which showed progressive improvement, and there was no other identified medical condition that would warrant continued testing since the Depo-Provera had been discontinued.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for a Dynasplint device. Findings:  The physician reviewer found that Furia and colleagues conducted a systematic review to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes. They concluded that dynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. John and colleagues conducted a randomized controlled trial to determine the efficacy of dynamic splinting in treating patients with postoperative hallux limitus. They concluded that dynamic splinting was effective in reducing contracture of postoperative hallux limitus. Experimental patients gained a mean 250% improvement in active range of motion (AROM). John and colleagues concluded that this modality should be considered for standard of care in treating postoperative hallux limitus.In this case, the patient had right foot bunionectomy performed and has developed a post-operative contracture of the big toe joint. This contracture has created a balance and gait disturbance. The patient has reportedly failed to adequately improve with splinting and exercise. Evidence based medical literature supports the use of dynamic splinting for treatment of this post-operative contracture as the standard of care. Under these circumstances, the requested Dynasplint device was, and is, medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested device was, and is, medically necessary for the patient's 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:  A 53-year-old female enrollee has requested reimbursement for emergency services including transportation. Findings: The physician reviewer found that according to the documentation submitted for review, the patient presented to the emergency department after an injury to the dorsum of her foot with a large piece of glass. She sustained significant continued blood loss following laceration repair, dropping her hematocrit from 32.8 to 30.6. After six hours of observation, the treating provider at the initial facility believed the patient required specialty consultation to assess for vascular and tendon injury. Failure to recognize a dorsalis pedis injury may result in acute foot ischemia or subsequent pseudoaneurysm formation. These services were not available at the initial facility. Despite the fact that the consultant believed that a significant arterial injury was not present, the patient yet may have injured a lesser artery or arteriole. The consultant still noted that there was a probable arterial injury but did not recommend further exploration. Further, due to continued active bleeding with a declining hematocrit, the patient required ambulance transport to the trauma facility for an evaluation. Until an acute vascular injury requiring surgical intervention could be ruled out, the patient continued to receive emergency services. For the reasons provided, the emergency services provided including transportation provided were emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. 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: Overturned

The patient is a 47-year-old woman who has a history of painful hammertoe and toenail fungus. A KOH preparation of her toenail was negative. The patient has elected not to take oral antifungals due to her concern about side effects, especially those involving the function of the liver. The patients provider recommended topical Penlac to treat the patients toenails and requested authorization from the Health Plan.  The Heath Plan determined the medication was not medically necessary, and denied the providers request.  Medically appropriate treatments for fungal nail infections include oral antifungals, fungoid solution, and Penlac solution. Oral antifungal medications are typically more effective than topical medications however, Penlac solution has shown some success and the risk of systemic side effects is less than minimal. The patient has expressed concern related to liver function with Lamisil, and she has asserted a preference for a topical medication.  As such, treatment with Penlac solution is medically appropriate. The patient should be monitored by her provider, and the therapy should be discontinued if it is not effective after a three-month trial.  Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for treatment from an inpatient chronic pain program.Chopra and colleagues evaluated current options for pain management of Ehlers-Danlos syndrome. Chopra and colleagues advocated a multidisciplinary approach, including physiotherapy for core stabilizing and joint stabilizing and proprioception enhancing exercises along with general fitness programs. They also recommended cognitive behavioral therapy and medication management with various classes of agents, including nonsteroidal anti-inflammatory drug (NSAIDs), neuromodulators, acetaminophen, and topical lidocaine. A study by Van Meulenbroek and colleagues assessed changes in disability, physical functioning, and other pain-related outcomes for hypermobile adolescents (age 12-21 years) with chronic musculoskeletal pain after following an outpatient multidisciplinary rehabilitation treatment. The treatment consisted of physical training and cognitive behavioral therapy, with the goal to improve physical parameters, such as aerobic capacity, muscle strength and proprioception. Cognitive behavioral therapy aimed to restore a normal pattern of daily functioning by decreasing pain-related fear. After treatment, the adolescents had lower levels of disability, decreased pain-related fear, a reduction in pain intensity and increased levels of physical functioning. Additionally, the medical literatures consensus is that a multidisciplinary approach is the main factor for best outcomes and not a clinical setting. No rationale has been provided identifying why multidisciplinary treatment would be unable to be provided in an outpatient setting. Therefore, treatment from an inpatient chronic pain program is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested weekly electro-acupuncture for treatment of his medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has been treated with multiple acupuncture sessions.  The acupuncture provider documented that after his last acupuncture series, the patient has improved activities of daily living, range of motion and reduction of pain levels. The acupuncture provider recommended an additional specific number of visits. Thus, further acupuncture treatment is medically necessary in this clinical setting to address the patients medical condition. However, as the provider has recommended a specific number of additional sessions for further functional improvement, such treatment plan is reasonable and medically necessary to help the patient transition to self-care. Moreover, open-ended treatment on a weekly basis is seen as maintenance in nature and not supported as medically necessary. Given the clinical documentation submitted for review, a portion of the requested services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in oriental 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 patients representative has requested authorization and coverage for brand name Tegretol XR, Lamictal 200 mg, and Lamictal 25 mg. Several recent studies have examined the effectiveness of brand versus generic anti-epileptic medication regimens. Researchers reported on a randomized, double-blind, multiple-dose, bioequivalence study comparing generic lamotrigine to brand Lamictal in generic-brittle epilepsy patients. The researchers found that brand and generic bioequivalence was similar and no patient subpopulation reacted poorly to generic or brand formulations. In addition, the American Epilepsy Society recognizes that well-designed, prospective studies of generic antiepileptic drug substitutions have demonstrated bioequivalence of generic products. Further, results from these studies have shown no difference in bioequivalence when switching from a brand product to a generic product or between multiple generic products. This patients records do not include documentation of intolerance to the generic formulations of Tegretol and Lamictal. His parent reports that the patient has been stable on the brand name medications for over 40 years. However, based on the current medical literature, the generic formulations of the requested medications are the bioequivalent and likely to be as effective as the brand name alternatives. Thus, the requested Tegretol XR, Lamictal 200 mg, and Lamictal 25 mg are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested brand name medications 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 48-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 not medically necessary for the treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for eating disorder intensive outpatient program level of care services. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient was admitted to the hospital for her eating disorder. The patient reported that she had eaten very little in three weeks. The discharge summary states that this statement was not likely given her normal weight and laboratory testing. The patient did not have any laboratory abnormalities, and when the patient left against medical advice, the provider reported that she was medically stable for discharge. Per the records, the patients interpersonal difficulties with healthcare providers is a barrier to effectively engaging and participating in eating disorder treatment. In this clinical setting, dialectical behavior treatment (DBT) is appropriate to gain emotional stability and would allow the patient to engage in eating disorder treatment. However, the records do not document the medically necessity for intensive outpatient program treatment at this time. Therefore, eating disorder intensive outpatient program level of care services are 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 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.