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

A 52-year-old female has requested BRCA testing  based on her family history of breast cancer.  Findings:  Three physician reviewers found that the patient presents with no personal history of cancer.  However, her mother, sister, and aunt have been diagnosed with breast cancer.  Her mother and sister were diagnosed with breast cancer at age 60, and her aunt was diagnosed with breast cancer at age 58.  The current medical evidence supports the requested testing in this clinical setting.  Screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  According to current guidelines, the requested testing is indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Restasis, or in the alternative, Xiidra. Restasis is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of dry eye disease. Patients with underlying inflammation have been shown to benefit from treatment with Restasis. This patient has dry eye syndrome. The records document that he previously experienced positive response with Restasis for the treatment of his dry eye disease. Given this support, the requested Restasis is medically necessary for treatment of this patient.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 ophthalmology 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 58-year-old female enrollee has requested a partial vulvectomy for treatment of her labial hypertrophy. Findings:  The physician reviewer found that there are many factors that can lead to labia hypertrophy including congenital, developmental, trauma, and infection. The patient states that this is a developmental occurrence and not from other factors. However, there is insufficient documentation of a work-up to establish that her labia hypertrophy is not the result of another condition. Thus, although the requested surgery is stated to improve pain and may try to create normal appearance, there is insufficient documentation to support these goals. There are no records demonstrating failure or intolerance to conservative measures to improve or to treat the patients pain. Overall, this patient may have functional concerns from her hypertrophic labia minora. However, given that the requested surgery is traditionally considered a largely aesthetic procedure, the treating providers must adequately describe the problem, functional concerns, non-surgical failures and work-up for other causes in order for surgical intervention to be medically reasonable in this instance. The procedure would be expected to improve the appearance, but lacking adequately defined functional improvement and justification for the procedure, the records do not satisfy the requested surgery as being reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a bone mineral density scan for evaluation of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The diagnosis of osteoporosis is made when the patient experiences a non-traumatic fracture regardless of the T-score.  In this case, the patient had a bone density study that indicated osteopenia.  At a later date she presented with an acute compression fracture, apparently not associated to trauma.  A bone mineral density study at this time might be useful to determine whether the patient has experienced significant bone loss in a short period of time, which should prompt the investigation and management of secondary causes for osteoporosis.  All told, the requested bone mineral density scan is medically indicated for the 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 sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for occipital nerve block therapy and prospective authorization and coverage for continued occipital nerve block therapy.Findings:  Two of the three physician reviewers found that occipital nerve blocks are a safe and medically reasonable treatment for occipital neuralgia and cervicogenic headache. In this case, the patient has documented objective findings consistent with occipital neuralgia. The patient also has a past medical history that is significant for occipital neuralgia, chronic pain syndrome, chronic myofascial pain, chronic cervical pain, facet arthropathy, and cervical and cervicogenic headache. Furthermore, the patient has previously undergone occipital nerve blocks with documentation of efficacy and durability of 4 months. Therefore, the patient has documented occipital neuralgia as well as documentation of the efficacy and durability of prior injection therapy to substantiate the need for repeat injection. Accordingly, the service at issue were and are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were and are 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 1, 2 and 3 are board certified in anesthesiology, with subspecialty certification in pain management, 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 parent of a six-year-old male enrollee has requested individual or group speech and language therapy once per week in the home and/or clinic setting for 60 minutes for treatment of his autistic disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has been diagnosed with autism with clear evidence of receptive and expressive language delays. The relevant scientific literature reveals that plasticity in the developing brain still exists, even in the presence of underlying neurologic disease, and can be utilized to improve overall neurologic health. Thus, specific treatment including modalities such as speech and language therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. Therefore, individual or group speech and language therapy once per week for 60 minutes is medically appropriate and necessary for treatment of the patients medical condition. The submitted evidence does not document any barriers to the patient receiving services in the clinic setting. As such, it is not medically necessary for the patients speech therapy to be home based.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl patch Td72 (12 mcg/hour). Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  The records document metastatic breast cancer.  This patient has tried and failed hydrocodone/acetaminophen.  She also reported that she has taken morphine.  She reports continued pain with activities of daily living.  The medical evidence supports the requested medication in this clinical setting.  There is evidence suggesting the superiority of fentanyl over oral agents due to less constipation.  Therefore, the requested fentanyl patch Td12 (12 mcg/hour) is medically indicated for the treatment of this patient. 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 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: Overturned

The patient is a 42-year-old female who had an abnormal screening mammogram in April 2006 which led to ultrasound of the breasts in May 2006. The ultrasound showed multiple cysts bilaterally with the largest cyst in the right breast measuring up to 1.4cm. In addition, within the left breast a 5mm hypoechoic defect with internal echoes was found at the 8 oclock position near the areola. This was felt to be either a complicated cyst or a solid mass and biopsy was recommended. The patient has a family history of breast cancer with a younger sister diagnosed at age 35, the paternal grandmother having a mastectomy at age 35 and the maternal grandmother dying of breast cancer at age 63. The patient was evaluated by a surgeon who ordered breast MRI which was performed in August 2006. The study showed cysts and proliferative changes with no evidence for malignancy. The patients request for reimbursement for bilateral breast MRI was denied by the Health Plan based upon a determination that the diagnostic procedure was not medically necessary.There are several indications for MRI of the breast which include a determination of the pre-operative extent of cancer, post-operative residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, the screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. This patient would be considered high risk because of her family history, which is a clinical indication for breast MRI under these circumstances. The negative MRI results however, do not change the ultrasound recommendation concerning the left breast lesion which should be followed closely or biopsied under ultrasound guidance.Based upon the information set forth above, I have determined the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested coverage for continuation and increased frequency of direct applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings: The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. Reichow and colleagues found that early intensive behavioral intervention is effective to increase IQ, and improve communication and adaptive skills. In this case, the patient has been treated with ABA therapy which has been effective for treating his communication, executive function and adaptive skills. Per the most recent progress note he has demonstrated mastery in inhibition of problem behaviors and stimulus orientation. In addition, he has shown mastery of responding to social cues. However, he continues to have non-compliance, emotional outbursts and vocal protest. The goals and curriculum of ABA are specifically designed to teach and ameliorate the core symptoms of autism including social deficits, communication deficits and adaptive skills. The Health Plans authorization of a reduction of hours per month of direct ABA therapy and of supervision is not indicated for this patient. Greatly reducing ABA services increases the likelihood of regression of skills already obtained. In this case, a portion of the requested ABA therapy, per month supervision and per month parent training was and is medically necessary for treatment of the patients autism.Final Result: The reviewer determined that a portion of the services at issue were and is 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 patient is a 59-year old female who sustained a fracture of the fifth metatarsal on her left foot in May 2004. The patient also has a history of diabetes, rheumatoid arthritis, and carpel tunnel surgeries. The patient underwent an open reduction-internal fixation surgical procedure to assist in bone healing. The submitted information indicates the patient utilized a manual wheelchair and a power-operated vehicle (POV) until November 2004. The Health Plan has denied reimbursement for use of the POV on the basis a POV was not medically necessary.The use of a POV is necessary when a patient is unable to operate a manual wheelchair. There is no evidence the patient was unable to utilize a manual wheelchair during the period at issue. Based upon the information provided, a manual wheelchair was medically reasonable and appropriate for this patient. There was no medical indication for a POV. Therefore, I have determined that the equipment at issue was not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested Lantus Solostar 100 unit/MI (3MI) subcutaneous insulin pen for treatment of her type I diabetes. Findings:  The physician reviewer found that the patient was using a short 30 gauge pen needle manufactured by Novo Nordisk for use with the Solostar pen. A review of the available medical literature reveals there are many manufacturers of pen needles. They are available in different gauges, 29  32, and lengths, 4  8 mm. There are at least 10 manufacturers of insulin syringes and they also come in the same gauges and short lengths, usually 8mm. Thus, the patient has the alternative of using short needles either attached to the Solostar or a syringe. Therefore, the use of a Lantus Solostar pen is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old female with presumed fingernail onychomycosis. A fungal culture has not been performed to confirm the diagnosis. There is no functional impairment noted. The patient has a reported history of hepatitis and has declined treatment with Lamisil. The patients request for authorization of Penlac was denied by the Health Plan citing a lack of medical necessity.The diagnosis of onychomycosis has not been confirmed. While it is medically appropriate to select treatment with Penlac rather than Lamisil due to the patients history of liver disease, it is not reasonable to treat her condition without a definitive diagnosis. In the absence of a confirmatory fungal culture, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for Synvisc injections for treatment of her knee pain. Findings:  The physician reviewer found that viscosupplementation as a component in the treatment of osteoarthritis of the knee has come to be an accepted procedure, especially in patients with mild to moderate arthritis, as noted by Dagenais. It is more efficacious in cases with minimal, or no, effusion, as noted by Gossec and Dougados.  Adverse reactions are usually infrequent and limited, and may be related to the injections. The use of viscosupplementation after the failure of exercise and other conservative measures or in situations of adverse events associated with medications has been recommended.  In this case, the patient has had recurrent effusion. There is no documentation of any employment of physical therapy, except for a self-exercise program, not otherwise defined.  There is no documentation of any adverse response to medications.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Case Summary: A patient who was diagnosed with an unresectable Stage 2 perihilar cholangiocarcinoma, bile duct cancer. The treatment discussed includes possible chemotherapy with radiation and evaluation for liver transplant. The patient began evaluation for egg preservation and underwent in vitro fertilization, specifically ovarian preservation in which seven mature oocytes were successfully retrieved and stored. MD Analysis:  At issue in this case is whether the fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) is medically necessary for treatment of this patient.According to the American Society of Reproductive Medicine (ASRM), egg retrieval and egg and/or embryo freezing (cryopreservation) is now a recognized option for women with cancer who are undergoing treatment that can be toxic to their ovaries and eggs, which can render them infertile. This option allows them to have children in the future. Although, they are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of chemotherapy. As noted in literature, treatment of malignancy...may necessitate surgical resection of reproductive organs or administration of gonadotoxic chemotherapy or radiation therapy. This often leads to infertility, which is a major quality of life concern. Researchers concluded, Cryopreservation of embryos is a proven effective technique for preserving reproductive capacity. In addition, researchers noted that discussion of fertility preservation and appropriate referral for treatment of reproductive age (and younger) cancer patients should be a routine part of cancer care, noting, Sperm and embryo cryopreservation and oocyte cryopreservation are considered standard practice. Given this support, the fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) is medically necessary for treatment of this 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 obstetrics and gynecology 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 parent of a 14-year-old female enrollee has requested reimbursement for the adolescent mental health residential treatment. According to the medical literature and best practice guidelines, residential treatment is used for acute stabilization and is not evidenced based for long-term type treatment. The American Academy of Child and Adolescent Psychiatry (AACAP) noted that residential treatment is appropriate when the provider has considered less restrictive resources and determined that they are either unavailable or not appropriate for the patients needs. In this patients case, less restrictive resources were available to safely and adequately address the patients needs. The patient was engaged in DBT and reported to her provider that she would continue DBT after she left residential treatment. All told, the adolescent mental health residential treatment was not medically necessary for treatment of the patients medical condition.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 psychiatry with sub-specialty certification in child and adolescent 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: Overturned

A 58-year-old female enrollee has requested a liver transplant evaluation by a liver transplant specialist for evaluation of her cirrhosis of the liver.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested service.  The patient has evidence of cirrhosis as evidenced by splenomegaly, thrombocytopenia, and synthetic dysfunction with an elevated bilirubin and international normalized ratio (INR). Cirrhosis due to any cause is an indication for liver transplant evaluation. Moreover, this patient has a model for end-stage liver disease (MELD) score of 11 and is therefore qualified to undergo liver transplant evaluation per accepted guidelines (Murray and Carithers). According to the American Association for the Study of Liver Diseases (AASLD) practice guidelines, The modified MELD score has been shown useful both in predicting short-term survival in groups of patients on the waiting list for liver transplantation as well as the risk of postoperative mortality. All told, the requested liver transplant evaluation by a liver transplant specialist is medically necessary for evaluation of the patients medical condition.