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

Nature of Statutory Criteria/Case Summary: The patient is a male with a history of osteoarthritis of the right knee. According to the progress note, the patient reported that over the last few years he has greatly benefitted from viscosupplementation, including pain relief lasting six months or more. The Synvisc One injection resulted in significant pain relief. The patient was able to reduce his need for non-steroidal anti-inflammatory drugs. The pain has since recurred, and the patient has requested authorization and coverage for Synvisc injection to the right knee. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. At issue is whether Synvisc one injection to the right knee is medically necessary to treat the patients medical condition.researchers found that viscosupplementation reveals mixed results.  Based on current medical evidence, viscosupplementation may be appropriate for patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Therefore, its well-documented that viscosupplementation works for this patient. As such, the request for Synvisc One injection into the right knee is medically necessary to treat the patients medical condition.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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment for treatment of his behavioral health conditions. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Per the medical records, the patients opiate use dominated his daily routine and generated distress.  He had strained relations with his family, and he did not have an established sober peer group.  He had failed outpatient treatment.  Despite starting escitalopram for mood and anxiety, the record indicates that the patient was anxious and dysthymic.  When considering the illness presentation in context of the history and psychosocial factors, the patient had not consolidated the treatment gains needed to facilitate a successful discharge.  The residential setting was reasonably expected to improve his condition and prevent a more serious episode of illness.  The duration of treatment was consistent with community standards.  All told, residential treatment was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the patients medical condition. Therefore, the Health Plans denial should be overturned.  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

A male enrollee requested magnetic resonance imaging (MRI) for medical evaluation of his shoulder pain.  Findings:  The physician reviewer found that per the clinical notes, physical examination does not detail laxity, weakness or other red flags to mandate immediate imaging.  The requirement of a trial of conservative management, including physical therapy, is a well-recognized precursor to advanced imaging, which is not documented in this case.  All told, the requested MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested authorization and coverage an ear, nose and throat (ENT) consultation (CPT code 99243) for treatment of her temporomandibular joint (TMJ) syndrome.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. According to the documentation submitted for review, the patient presents with TMJ dysfunction. The American Association of Oral and Maxillofacial Surgeons (AAOMS) indicate that conservative therapy is the mainstay in treating TMJ pain and disorders. Per AAOMS conservative therapy includes behavioral change, oral medications for pain, anti-inflammatory injections, and orthotic devices. In this clinical setting, standard non-surgical treatments and an assessment of treatment outcomes are indicated prior to a referral to an ENT specialist. Therefore, the request for an ENT consultation (CPT code 99243) is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in otolaryngology and head and neck 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: Overturned

The parent of a 15-year-old female enrollee has requested  24 additional occupational therapy (OT) visits for treatment of the enrollees medical condition status post dislocated elbow with fracture.  Findings:  The physician reviewer found that this patient continues to have pain and a loss of elbow range of motion despite treatment with occupational therapy. She has a complication of heterotopic ossification which prolongs the recovery from this type of injury (Ellerin, et al.). There is little evidence in the medical literature that provides conclusive evidence that one treatment modality is superior to another in this clinical setting. However, given the documented gains the patient with previous therapy and the fact that she continues to have pain and loss of range of motion, the requested additional occupational therapy sessions have been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested anesthesia services provided for a gastrointestinal endoscopic procedure for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  Colonoscopy and esophagogastroduodenoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care.  The medical evidence does not support the medical necessity of the services at issue in this clinical setting.  All told, anesthesia services provided during a gastrointestinal endoscopic procedure were not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Factor V Leiden (FVL) Mutation Analysis lab testing. The submitted documentation supports the medical necessity of the requested testing. Factor V Leiden (FVL) is a mutant form of coagulation factor V. Multiple studies have demonstrated that there is an increased risk of venous thromboembolism (VTE) in individuals with the FVL mutation. The risk of VTE can further be increased with aging, homozygosity for the FVL mutation, or coinheritance of another thrombophilia with FVL. The risk of VTE can also be increased with acquired factors such as pregnancy or oral hormonal contraceptives and cancer. Testing in individuals under the age of 45 and/or someone with a family history of blood clots is considered a standard of care. In this case, has a family history of blood clots, and has a recent history of DVT. Under these circumstances, the requested Factor V Leiden (FVL) Mutation Analysis lab testing is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in hematology, 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 fifty-one year-old female diagnosed with stage IV non-small cell lung cancer is requesting reimbursement for intensity modulated radiation therapy (IMRT).Reviewers Findings:  The reviewing physician found that there is no evidence IMRT was likely to be any more efficacious for this patient than standard radiation therapy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old female with a body mass index (BMI) of 61, which is diagnostic for super morbid obesity. The submitted records indicate the patient has asthma and familial lymphedema. It does not appear the patient has obtained psychiatric clearance for weight loss surgery. The patient wishes to undergo gastric bypass surgery. The Health Plan has denied authorization and coverage for gastric bypass surgery on the basis that it is not medically necessary.With a BMI of 61 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients super morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorization of weight loss surgery. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that she presented for a mammogram because of a palpable abnormality in her right breast. She has a strong family history of breast cancer.  She has been tested for BRCA1, and is negative. She underwent a mammogram consisting of a three-dimensional (3D) tomosynthesis study with synthetically reconstructed two-dimensional (2D) views. In addition, she had a targeted sonogram of the palpable region of her right breast. The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Benign calcifications were seen. Her breasts were described as dense. The patient has requested reimbursement for the digital breast tomosynthesis. The Health Plan has denied this request as investigational. The digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has breasts that have been described as dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. In addition, the ability to separate out the overlapping structures enables the possibility of demonstrating or excluding an otherwise occult tumor. For the reasons provided, the services at issue were 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 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 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: Medical Necessity
Decision: Overturned

A forty-eight year-old female who is diagnosed as having myasthenia gravis (MG) is requesting authorization and coverage of past and future at-home IVIG treatments.  Reviewers Findings:  The reviewing physician found that Typically, IVIG is used in MG as an acute therapy for MG crisis. It has been shown to have similar efficacy to plasmapheresis in the treatment of acute MG exacerbations.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested for a breast MRI for evaluation of her HER2-positive, high-risk, primary left breast cancer.   Findings:  Three physician reviewers found that the treating oncologist has requested MRI imaging of the left breast for current follow-up and clinical decision-making. There is tissue induration at the surgical site on palpation, and the breast implant left in place interferes with the proper mammographic visualization of the left breast tissue. Thus, physical exam and standard mammography are clearly compromised in this setting and have impaired diagnostic specificity.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1a. 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni. These 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as 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 for Facial Feminization Surgeries (CPT code 15824: rhytidectomy, forehead; CPT code 30410: rhinoplasty, primary, complete; CPT code 20926: tissue graft, other; CPT code 15829: rhytidectomy, SMAS flap; and/or CPT code 15876: suction assisted lipectomy).The purpose of medically necessary facial feminization surgery is to relieve gender dysphoria, which the surgery does through harmonization with regard to other modified structures, achieving an aesthetic result beyond gender difference (Capitan, L., et al., 2020). The World Professional Association for Transgender Health (WPATH) has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. The WPATH has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition (WPATH, 2016). Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life (Ainsworth and Spiegel, 2010).In this case, documents indicate that the patient has a diagnosis of gender dysphoria. Progress notes indicate that the requested procedures are necessary in order to feminize the patients face. The progress notes explain that due to the patients gender dysphoria, accomplishment of the requested procedures will allow the patient an ability to appropriately assimilate into society as a female and will permit her to more fully self-identify as a female. Under these circumstances, the requested Facial Feminization Surgeries (CPT code 15824: rhytidectomy, forehead; CPT code 30410: rhinoplasty, primary, complete; CPT code 20926: tissue graft, other; CPT code 15829: rhytidectomy, SMAS flap; and/or CPT code 15876: suction assisted lipectomy) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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

A 52-year-old male enrollee requested authorization and coverage of a tandem autologous stem cell transplant for the treatment of multiple myeloma.  The health plan denied the enrollees request indicating that the requested tandem autologous stem cell transplant 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 treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested authorization for inpatient psychiatric treatment services for treatment of her polysubstance abuse and eating disorder.  Findings:  The physician reviewer found that the appropriate level of care would have been outpatient therapy with nutritional consultation. The admission to the eating disorder program at the residential level of care was not clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested  for the medication Zyrtec for treatment of his asthma. Findings:  The physician reviewer found that there is no documentation provided necessitating the approval of Zyrtec at this time. The patient requires a trial of nasal spray prior to prescribing Zyrtec.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the American College of Radiology (ACR) recommended that breast tomosynthesis be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional (2D) imaging mammographic protocol was likely of more benefit to this patient than if the exam had been performed using the two dimensional technique alone. 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 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.