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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bunion surgery for treatment of the enrollees bunion. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Hallux valgus is a biomechanical malformation of a foot, causing strain and most often pain to the first metatarsophalangeal joint.  This patient complains of painful first metatarsophalangeal joint unresponsive to conservative care including steroid injections to the metatarsophalangeal joint.  She also relates a history of trauma which may exacerbate a bunion deformity.  In this clinical setting, a bunionectomy for hallux valgus is standard of care and may be beneficial in alleviating the first metatarsophalangeal joint pain for the patient.  All told, the requested bunionectomy is medically necessary for the 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 physician reviewer is board certified in podiatry 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 63-year-old male enrollee requested authorization and coverage of a referral to a cardiologist for the treatment of hypertension, hyperlipidemia, overweight, COPD, and gout.  The enrollee is status post coronary artery bypass graft in 1999.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter aortic valve replacement. Researchers note a central component for transcatheter aortic valve replacement (TAVR) consideration is the underlying risk for surgical aortic valve replacement, based on the STS score. Researchers reported that while TAVR is an alternative to surgery in patients with severe aortic stenosis who are at increased risk for death from surgery, TAVR was noninferior to surgery even for patients with low surgical risk. In this case, the patient has severe aortic stenosis, increasing symptoms of dyspnea on exertion, and several comorbidities, including moderately severe pulmonary hypertension, asthma, and hepatic cirrhosis, with an elevated STS surgical mortality risk of 3.45%. She was evaluated by a comprehensive heart team, including a cardiac surgeon and a cardiologist, and the team recommended TAVR based on these factors. Therefore, transcatheter aortic valve replacement is medically necessary for the treatment of this patient.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 sub-specialty certification in cardiovascular disease 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: At issue in this case is whether all or any of the residential treatment center services that were received were medically necessary to treat the patients medical condition. The patient was admitted to RTC services admitted to the residential treatment center (RTC) approximately one-year prior for diagnoses that included anxiety, gender dysphoria, attention deficit hyperactivity disorder, and dysthymia.Applying the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS), providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System to help determine the appropriate level of care. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients presentation a composite score of 16 correlating with a lower intensity level of care than RTC.Final Result: The reviewer determined that the requested services 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that per the most recent guidelines issued, all patients with chronic hepatitis C should be treated regardless of fibrosis except those with limited life expectancy due to non-liver-related conditions. However, the requested regimen of Sovaldi and ribavirin for 24 weeks is no longer recommended by the guidelines. Non-cirrhotic genotype 3 patients who have failed PEG-interferon and ribavirin are recommended to be treated with Sovaldi, PEG-interferon, and ribavirin for 12 weeks or Sovaldi and Daklinza for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Sovaldi and ribavirin for 24 weeks is not supported as medically necessary for the treatment of this patients hepatitis C virus. Final Result: The reviewer determined that the requested 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 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 there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis has resulted in a decrease in callbacks and increase in detection of small cancers when the technique is used in conjunction with two-dimensional imaging.  The addition of breast tomosynthesis to digital mammogram has gained endorsement by radiologists due to the added advantages.  All told, the addition of breast tomosynthesis was likely more advantageous to this patient than had the mammogram been done with two-dimensional imaging alone.  Final Result: Two 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.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested hospital services for transfer to a contracted hospital. Findings:  The physician reviewer found that the submitted documentation demonstrates that the patient was stable for transfer to a contracted facility on the date in question.  This patient was hospitalized with a life-threatening infection on the date specified.  The medical records noted HIV infection and Pneumocystis pneumonia.  However, by the subsequent date specified, he had markedly improved.  The clinical notes indicate that the patient could have safely transferred to another facility as of this date.  Thus, it was not medically necessary that the patient receive care at the non-contracted facility from the time frame specified.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested water physical therapy for treatment of his multiple sclerosis and sciatica. Findings:  The physician reviewer found that this patient does not have a condition for which water physical therapy is medically necessary.  The patient has weakness in the limbs, but not to the degree that he cannot participate in land-based therapy.  Notably, he has undergone extensive land-based therapy to date, including very recently.  While participation in some exercise is generally encouraged in the setting of multiple sclerosis for symptoms such as fatigue, there is a lack of high-grade evidence of its benefit.  Additionally, there is no specific recommendation supporting the need of aquatic therapy, particularly if land-based therapy is feasible.  The Health Plan has offered continued land-based physical therapy, and this alternative is medically reasonable and appropriate in this patients case. All told, the requested water physical therapy is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female has requested occupational therapy for treatment of her autism. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers (Shevell, et al.). The main goal of treatment is to enhance the patients level of functioning. This patient has delays in gross motor skills, fine motor skills, social/personal skills, and activities of daily living. There is a history of acquired hydrocephalus noted. A study by Ding, et al. noted that disorders of gross and fine motor movements are commonly observed in hydrocephalus. The findings of the study indicated that with practice and training procedures, improvement in motor-skill learning was observed (Ding, et al.). Further, Wolraich and colleagues note that occupational therapy is medically necessary in this setting to promote adaptive skill development and to improve fine motor abilities and independence. All told, this patient has documented deficits in gross motor skills, fine motor skills, social/personal skills, and activities of daily living, and thus, is an appropriate candidate for occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of his rectal cancer. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) recommends that IMRT only be used in a clinical trial or when there are unique clinical circumstances such as irradiation of recurrent disease after previous radiation (Benson, et al). In this patients case, the records do not support the medical necessity of treatment with IMRT.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old woman with diabetes mellitus with a history of onychomycosis. The patients primary care physician prescribed Lamisil 250mg daily for a period of three months to treat her onychomycosis. It appears the patient began treatment with Lamisil in December 2003. Laboratory results after 12/4/03 have not been provided. The patients provider has recommended continuation of treatment with Lamisil. The Health Plan indicates that the requested medication is not medically necessary.It is medically necessary for diabetics with onychomycosis to be treated with systemic medication. However, given the lack of recent clinical data provided it is not known if the patient still has documented onychomycosis. The patient should be evaluated and treated by a dermatologist to determine whether the clinical and fungus culture criteria for onychomycosis are present. If upon physical examination, history, and fungus culture it is determined that onychomycosis is present then another three-month course of Lamisil would be medically indicated.  Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. Therefore the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is being treated for hepatitis C, type 1b. After three months of therapy, the patient has not cleared his virus and he has not had a 2-log drop in viral count. The patients providers recommend the patient receive a full year of therapy. The Health Plan indicates that continuation of Peg-Intron and Rebetol therapy is not medically indicated given the patients insufficient response to the initial therapy.The Health Plans denial should be upheld. It is not the standard of care to retreat patients who have not responded to an initial course of Peg-Intron and Rebetol therapy. The article by Fried, et al. cited above clearly shows that if a patient does not respond to Peg-Intron and Rebetol therapy within three months (i.e., experiences a 2-log drop in viral count or undetectable viral count), there is a 97% certainty that the patient will not respond to continued therapy. Thus, continuation of Peg-Intron and Rebetol therapy is not likely to benefit the patient and is not medically indicated. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral brachioplasty. According to the American Society of Plastic Surgeons (ASPS), When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. This patient has excess skin on her upper arms from massive weight loss. She complains of discomfort and intertrigo under her arms, but there is no report of appropriate medical treatment of intertrigo or of failure of appropriate medical treatment of intertrigo. Active intertrigo is not present on physical examination. The patient does not have a functional problem with intertrigo under her arms that has been demonstrated to be resistant to appropriate medical treatment. Based on the evidence-based literature, the requested bilateral brachioplasty is not medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. This patients lax skin under the arms is not an abnormal condition of the body that is the result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. The lax skin is a normal structural change that is an accommodative response to the gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The requested procedure will not provide a more than minimal improvement in the patients appearance. All told, the requested bilateral brachioplasty is not reconstructive in nature 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hyperbaric oxygen therapy. Findings:  The physician reviewer found that the use of hyperbaric oxygen therapy for treatment of this patients medical condition is supported by peer reviewed literature. The patient experienced bilateral ischemic skin flaps following his rhytidectomy. The submitted records indicated that the patient had struggling vascularity to his skin flaps. Ischemic skin flaps are known possible complications following rhytidectomy. The initial measures attempted included suture removal to lessen the tension on the flaps. With continued ischemia, the patient was recommended for hyperbaric oxygen treatment and he underwent this treatment. A study by Freidman and colleagues demonstrated that hyperbaric oxygen therapy, either alone or in combination with other modalities, should be considered when treating compromised flaps in certain situations. In this patients case, the patient had compromised skin flaps and the hyperbaric treatment was used in conjunction with other measures to improve skin survival. A retrospective study by Larson and colleagues concluded the following, This study provides clinical data characterizing and supporting the application of hyperbaric medicine to aid in the viability of compromised flaps.  The medical literature supports the use of this adjunctive treatment to lessen the degree of necrosis, as in this patients case. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested anterior optical coherence tomography (OCT) for evaluation of her medical condition. Findings: Two physician reviewers found that an anterior segment OCT is a technology that has been used in assessing the status of the angle of the eye. It provides information that cannot be obtained from gonioscopy, especially the status of the angle in light versus dark. However, OCT is not indicated to check the angles of a patient who has been diagnosed with narrow angles. Gonioscopy is the standard of care and that has been already performed. Further, the patient has already undergone peripheral iridotomy, which will prevent angle closure from occurring. An OCT evaluation does not add any clinically significant value towards management of this patient. Thus, the requested anterior OCT was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the diagnostic procedure 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 ophthalmology and are actively practicing. All three reviewers are an 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: Upheld

A male enrollee requested monitored anesthesia care (MAC) for medical treatment of his medical condition.  Findings:  The physician reviewer found that the monitored anesthesia care services were not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. In this clinical setting, the patient could have received a combination of a benzodiazepine and narcotic for sedation. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parents of an 11-year-old male enrollee have requested interactive metronome therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that interactive metronome therapy is investigational as there is a lack of published evidence demonstrating its efficacy. There is a lack of literature supporting improvement in outcomes for this patients condition. As such, there is inadequate evidence establishing that the requested therapy is likely to result in an improved clinical outcome for this patient.