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

A 57-year-old male enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of his prostate cancer. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. The standard of care for early stage prostate cancer includes prostatectomy, interstitial brachytherapy and IMRT delivered over seven weeks. SBRT, delivering high fractional doses to the prostate in 3-5 fractions is an emerging approach to the treatment of prostate cancer. However, longer-term follow-up and randomized controlled phase III clinical trials are needed before SBRT becomes a standard treatment method. Moreover, SBRT for the treatment of prostate cancer encompasses an entire gland while generally only a few TRUS biopsy cores are positive for prostate cancer. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Phenergan. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient reports chronic nausea with a history of chronic gastritis. Possible etiologies of her nausea include migraine headaches and medications, including opiate analgesics. The patient has requested continued use of Phenergan for her symptoms, and her provider has noted that this medication has increased risk of potentially harmful side effects. The treatment of chronic nausea should include a thorough history and physical examination. There should be an attempt to discover the etiology of the nausea, including as a side effect of other medications. Testing should be guided by the symptom duration and characteristics of symptoms. Targeted treatment should be provided. Although Phenergan is an antiemetic that may partially alleviate acute nausea and vomiting, there is a risk of hypotension and extrapyramidal side effects. In this case, the patient is requesting a potentially harmful drug for the treatment of chronic nausea that has not been clearly defined or investigated. Her provider has offered an alternative medication with a safer side effect profile, Zofran. Furthermore, it is possible that the nausea is due to opiate use, in which case a taper from this medication would be appropriate to try to treat and prevent further nausea. Therefore, Phenergan is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 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 for a positron emission tomography (PET) scan for evaluation of the enrollees squamous cell carcinoma of the rectum. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patients initial PET scan was positive.  Subsequently, on the follow-up PET scan, there was a partial response with diminished uptake.  Complicating matters, however, is that radiation therapy can, in itself, result in fludeoxyglucose (FDG) uptake.  Thus, while it is a good sign that the activity on the follow-up PET scan had diminished, one does not know whether there are post radiation changes or whether there is residual tumor.  The patient then had another follow-up PET scan in the spring which again revealed residual activity.  Generally, the changes related to radiation therapy should be resolving after six months, and it was presumably this residual activity which led her provider to perform a repeat endoscopy and biopsy.  The biopsy results were negative.  However, at this point, it is still not clear whether there is residual tumor.  The fact that her biopsies were negative does not exclude the possibility that the residual tumor simply was not sampled.  At this point, the FDG activity should be diminishing.  If not, there is a more likely possibility that there is residual tumor.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested PET scan is medically indicated for the evaluation 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 diagnostic radiology 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 including terino malar shell implants; genial advancement; subnasal lip lift; a Kenalog injection to the forehead; and neck lift. The World Professional Association for Transgender Health (WPATH) has stated that medically necessary gender affirming/confirming surgical procedures include certain facial plastic reconstruction. The WPATH further states that the medical procedures that are attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The Transgender Medicine Model NCD Working Group has also explained that other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women include reconstructive facial feminization surgery. These procedures are not cosmetic; rather, they serve a reconstructive purpose for transgender women whose overall physical appearance otherwise prevents them from being perceived as female. In this case, the submitted records reflect that the patient has a documented history of gender dysphoria. The patient has been on cross-gender hormone therapy and has had other gender confirming surgeries, and her gender dysphoria has not been alleviated by these other treatments. While the surgeon and primary care provider do not clearly state how the requested procedures will address the patients gender dysphoria, a letter from the patients psychologist is convincing. The psychologist attests at length and with emphasis how the facial feminization surgery is needed to therapeutically treat the patients gender dysphoria and relieve the patients distress. Under these circumstances, the requested facial feminization surgeries are medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested procedures are medically necessary for treatment of the patients behavioral health 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic hepatitis C should be treated with antiviral therapy regardless of fibrosis score.  The medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 33-year-old male enrollee has requested bilateral mastectomies for treatment of his gynecomastia. Findings:  The physician reviewer found that an article by Rohrich and colleagues has an algorithm for evaluation and treatment of gynecomastia. The authors recommend obtaining a detailed patient history and physical examination in addition to the classification or grading of gynecomastia. This patients medical documentation does not fulfill the requirements for bilateral mastectomy for the treatment of gynecomastia. Although the patients condition has been present for more than one year, the records fail to document the specifics of the patients condition including the findings on physical examination, photographic evidence, or data probative of the patients need for the requested surgery. Without this data, the patients condition cannot be graded according to the American Society of Plastic Surgeons classification grading system, which is important to further define the nature of the abnormality. In addition, the records do not document the use of analgesics, if and when the medication was discontinued, and whether the patients gynecomastia is the result of another underlying cause. Although the provider recommended the patient undergo an endocrinology consultation for the stated purpose of ruling out hormonal causation, it does not appear that this examination has occurred. Further, this patient has not undergone a tissue diagnosis by incisional or excisional biopsy which may reveal a malignancy that would clinically justify the necessity of a mastectomy. Thus, further evaluation is indicated before surgery should be considered for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee requested authorization and coverage of orthotripsy for the treatment of chronic heel pain.  The health plan denied the enrollees request indicating that the requested service is not medically necessary.One podiatrist reviewer performed a medical necessity Independent Medical Review.  The podiatrist reviewer overturned the health plans denial on the basis that the requested orthotripsy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 functional electrical stimulation (FES) cycle therapy system. Findings:  Two of the three physician reviewers found that there is a lack of support for the requested device in this clinical setting. Ralston and colleagues noted that there were no clear effects of functional electrical stimulation (FES) cycling on urine output, swelling and spasticity even though all point estimates of treatment effects favored FES cycling and participants perceived therapeutic effects. This patient presents with tetraplegia and associated neurological deficits in the bilateral upper and lower extremities below the C5 level. At this time, there is a lack of definitive clinical research demonstrating the benefit of FES units as an adjunct treatment for spinal cord injury. Therefore, the requested RT300 FES cycle therapy system is not likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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 21-month-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) recommends speech therapy for children with autism. Specifically, the organizations state that The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. In addition, to speech and language deficits, the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction and behavior. Studies have shown that occupational therapy prevents deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Thus, speech therapy and occupational therapy are standard of care modalities for patients with autism. Given this patients deficits associated with his diagnosis of autism, it is medically necessary for him to receive the requested speech therapy and occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested for Roux-en-Y gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the patient is morbidly obese and has tried non-surgical approaches to weight loss and these have been unsuccessful.  However, she presently does not have medical evidence of a significant comorbid condition.  The patient recently cancelled an evaluation that would have confirmed or ruled out obstructive sleep apnea, one such comorbidity.  Based upon the information provided there is no evidence the patient meets nationally accepted criteria for consideration of gastric bypass surgery.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old male who is HIV positive and under the care of a HIV care physician who has requested a recombinant human growth hormone (Serostim) to treat severe lipohypertrophy (also referred to as visceral adipose tissue accumulation or lipodystrophy).He is described as having massive accumulation of intra-abdominal fat, which interferes with his activities of daily living and has caused shortness of breath and exacerbated his asthma by compressing the diaphram and causing obstructive lung disease. In addition, both a neurologist and a neurosurgeon have diagnosed neuralgia parasitica causing numbness of the thighs, legs and feet. The cause of this is nerve compression caused by progressive increase in abdominal girth due to the visceral fat accumulation of HIV lipodystrophy. Activities of this normally active and fit patient have been severely curtailed.At issue is whether the requested injections are medically necessary for treatment of the patients medical condition.Lipohypertrophy is a relatively newly recognized condition in patients with HIV and the cause is unknown. It is believed to be multifactorial, with HIV infection, insulin resistance and antiretroviral medications all playing some role. To date, there is no FDA approved treatment for this condition; however, results of clinical trials of human growth hormone are under review. Liposuction is often ineffective and cannot be performed on intra-abdominal fat and the fat often quickly reaccumulates anyway. While diet and exercise may help, they do not reverse the condition. Metformin and testosterone replacement may also play a role, but have not been proven effective.The results of a placebo controlled, double blind trial with 245 HIV patients testing rhGH in abnormal visceral adipose tissue accumulation show significant improvement in patients who received rhGH. There are also numerous pilot studies that suggest it may be the most effective treatment thus far, and there are many reports of dramatic improvement in certain patients with lipophypertrophy. As such, use of growth hormone in this patient is medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested injections are medically necessary for treatment 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 a minor enrollee has requested authorization and coverage for an insulin pump. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees type I diabetes. Findings: The physician reviewer found that there is support in the documentation as well as in the medical records for the requested device in this clinical setting. This patient has a history of widely fluctuating blood glucose levels before meals, despite multiple dose adjustments and frequent blood glucose monitoring while receiving a multiple dose insulin injection regimen, which they have implemented since their initial diagnosis more than six months ago. Although their glycemic control is good, based on their recent HbA1c of 7.4%, they continue to have wide glycemic excursions and variations in their daily activity schedule and eating plan such that a multiple dose injection regimen is unlikely to be adequate to treat their diabetes. Several studies published in peer reviewed journals have shown that insulin pump therapy is safe and effective in children and adolescents who are diagnosed with type I diabetes. The medical literature indicates that when compared to conventional insulin, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, and reduces the frequency of hypoglycemic events. Accordingly, the results affect the overall satisfaction of patients and their parents. In addition, this patients care givers have demonstrated that they possess the necessary tools to carry out an effective treatment and follow up plan while this patient is on insulin pump therapy. Specifically, the patient and their family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have adhered to dietary recommendations. For these reasons, insulin pump therapy is medically necessary for treatment of this patients diabetes. Final Result: The reviewer determined that the requested device 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 acupuncture. Findings:  The physician reviewer found that In reviewing the records available, there is no documentation that the patient has undergone an acupuncture trial. Given the patients continued symptoms despite previous care including physical therapy, medications, yoga and self-care, an acupuncture trial for pain management and function improvement is reasonable. Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Also, a recent randomized controlled trial comparing usual care to acupuncture plus standard therapies found that at 24 months, patients treated with acupuncture with standard therapies were more likely to report 12 months decreased pain and were less likely to require use of pain medication. Consequently, the requested acupuncture is supported as medically necessary for treatment of this 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 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: Overturned

A 51-year-old female enrollee has requested for gall bladder surgery for treatment of her gall bladder condition and liver hemangioma.   Findings:  The physician reviewer found that although the liver hemangioma is not close to the gall bladder fossa, and the chance of the spontaneous rupture is less than 1%, it nonetheless presents a surgical risk.  Technical expertise certainly would reduce that risk.  The availability of vascular back up during surgery is medically reasonable and appropriate to address this risk.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old male enrollee has requested teduglutide (Gattex) for treatment of his short bowel syndrome, hypercoagulable state on Coumadin, portal and mesenteric vein thrombosis, malnutrition, and vitamin deficiencies prior to total parenteral nutrition (TPN), and delayed gastric emptying.  Findings:  The physician reviewer found that the patient has evidence of intestinal failure due to short bowel syndrome. The patient continues to complain of severe diarrhea and episodes of dehydration. Gattex has trophic effects on the small bowel and increases mucosal blood flow. One study conducted over 52 weeks with Gattex compared to placebo showed a significant improvement in patients TPN requirements with an average 20% decrease when treated with Gattex (OKeefe, et al). The patients also reported improved quality of life due to decreased diarrhea. Consistent with this patients condition and the support for use of Gattex in this patient population, the requested Gattex is medically necessary for treatment of this patients medical condition.