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

A 51-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested therapy. The medical records provided for review indicate the patient stopped TMS therapy and began to deteriorate within months. By the date indicated, the patient stopped TMS therapy and began to deteriorate approximately four months later. The medical literature recommends TMS treatment, generally a 4-6 week trial depending on the patients progress. In this case, the patients treatment phase indicates that the patient had TMS treatment for about a six month period. The treatment phase notes that the patient underwent TMS for a four month period. Both times the patient began to deteriorate within a very short period of time. Thus the effectiveness of the treatment at issue for this patient has not been established in this clinical setting. In sum, based on the medical records submitted for review, there is a lack of adequate evidence that this treatment approach is effective and medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a user adjustable heel height component for her prosthesis for the treatment of the enrollee, who is status post amputation. Findings:  The physician reviewer found that the patient has low back pain. However, the diagnosis of scoliosis and its severity has not been established in the documentation provided. If the patient does have scoliosis, a user adjustable heel height component should not be used, as changing the length of the lower extremity will increase pain. Thus, the user adjustable heel height component was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee requested authorization and coverage of Actiq 1600 mcg. The Health Plan denied the request indicating that the requested prescription is not medically necessary for the treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested prescription is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction revision/exchange bilateral breast implants for treatment of the enrollees congenital marked asymmetry of the breasts and reconstructive in nature. Findings:  The physician reviewer found that congenital breast deformity is a well-recognized condition that may be amenable to breast reconstruction. In this patients case, she has a painful capsular contracture that can be considered a complication of her original reconstructive surgeries. Thus, the proposed surgery is considered medically necessary to treat a functional impairment. Further, as stated by the American Society of Plastic Surgeons (ASPS), attempts at correction of these deformities should be considered reconstructive surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Based on the medical documentation provided for this review, the patient has a congenital breast deformity that required right breast reconstruction with an implant initially, followed by bilateral reconstruction that included a contralateral mastopexy. This patients original surgery was reconstructive as it was performed in order to correct a congenital deformity. Based on the most recent documentation, the patient has moderate deformity and symptomatic capsular contracture. This would be considered abnormal appearing breasts. She presents with a painful capsular contracture which is a complication of her original reconstructive surgeries. Thus, any correction of a complication as a result of reconstructive surgery should be considered reconstructive as well. Therefore, attempts to approximate a more normal appearance should be considered reconstructive and not cosmetic. Further, the proposed surgery is likely to result in more than a minimal improvement in the appearance of the patient. For these reasons, the requested breast reconstruction revision/exchange bilateral breast implants is supported as medically necessary for treatment of this patients congenital breast deformity and reconstructive in nature. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ubrelvy 100 mg. The current medical evidence supports the requested medication in this clinical setting. Ubrelvy (ubrogepant) is an oral calcitonin gene-related peptide (CGRP) inhibitor that has been approved by the U.S. Food and Drug Administration (FDA). Ubrelvy is indicated for the acute treatment of migraine with or without aura in adults. Dodick and colleagues performed a randomized trial evaluating the efficacy, safety and side effect profile of Ubrelvy. The authors noted, A higher percentage of participants who received ubrogepant than of those who received placebo had freedom from pain and absence of the most bothersome symptom at two hours after the dose. Although the American Headache Society guidelines have not been updated recently to include oral CGRP receptor antagonists, an addendum article by Pringsheim and colleagues recommended, When an initial treatment (for an acute migraine) does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive medications. Ubrelvy is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults. Therefore, Ubrelvy 100 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. The records provided for review document that this patient was hospitalized after collapsing following a period of self-neglect, including severely reduced food intake. The patient was medically stabilized and functionally improved over a prolonged period of time, to ambulating household distances with a walker with stand-by assistance to supervision level. By the date of the Health Plans denial, the patient continued to require some ongoing physical assistance for self-care tasks, but this level of assistance could have been provided in the community. The patient did not require ongoing rehabilitation, skilled nursing services, or medical care in a SNF. The patient was able to undergo routine blood tests to monitor for anemia on an ambulatory basis. The patient has a history of chronic hip pain and was scheduled for an upcoming hip replacement, which is an elective intervention for end stage osteoarthropathy failing conservative care. The patient has not required SNF services to await hip replacement surgery. All told, the SNF services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 62-year-old female enrollee has requested for two series of hyaluronan injections (Euflexxa) for treatment of her osteoarthritis.  Findings:  The physician reviewer found that this patient was a reasonable candidate for Euflexxa and the therapy was provided at reasonable intervals. She has documented evidence of arthritis and has undergone an unsuccessful trial of conservative treatments including rest, medication, analgesic, creams, braces and physical therapy. MRI studies revealed significant arthritis with associated meniscal tearing. The benefits of Euflexxa for the treatment of osteoarthritis are well documented. There have been several studies suggesting that arthroscopy and debridement for arthritic knees are not helpful, leaving the patient with very few treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old male enrollee has requested surgical resection of recurrent peritoneal sarcoma for treatment of his retroperitoneal liposarcoma.  Findings:  The physician reviewer found that the patient has been evaluated by a non-Plan provider who noted the presence of multiple well circumscribed recurrent masses in the retroperitoneum involving the right kidney and possibly other structures; based upon this evaluation, the provider recommended radical resection for purposes of palliation. It is well-established in surgical oncology that radical excision of soft tissue sarcomas is justified for palliation by cytoreduction. In this patients case, he has exhausted all other treatment options. An attempt at surgical resection is medically reasonable in order to provide symptom relief and improve quality of life. Therefore, the requested surgical resection of recurrent peritoneal sarcoma is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old female enrollee has requested a consultation with a clinical audiologist for the evaluation of the enrollee for possible central auditory processing disorder (CAPD). Findings:  The physician reviewer found that in order to determine if the patient does have an auditory processing disorder, she will need to be evaluated by a licensed clinical audiologist with expertise in auditory processing evaluations and treatment.  These evaluations are exclusively within the scope of practice of clinical audiologists and no other clinical professional.  Because central auditory processing disorders represent a medical and not an educational condition, the evaluations are medically necessary. Clinical audiologists are licensed clinicians who are trained to conduct medically necessary evaluations to diagnose impairments of the auditory and vestibular systems. Auditory processing disorders represent a dysfunction of neural processing within the central auditory pathway. Because auditory processing disorders typically fall into one or more of four classifications, the recommended therapy and treatment are individualistic and not universally applied. Until this patient is evaluated and diagnosed positively or negatively with an auditory processing disorder, the appropriate therapeutic and/or educational goals will be incomplete.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested for a new C-Leg for treatment of her above the knee amputation.  Findings:  The physician reviewer found that the studies published regarding this prosthetic component are very small, precluding the drawing of firm, objective conclusions. One study comparing a microprocessor-controlled knee versus a standard knee use in transfemoral amputees demonstrated no significant advantage of the microprocessor-controlled knee design in terms of daily activities and endurance over the standard design (Klute, et al). Another study compared patients with transfemoral prostheses with microprocessor-controlled knees versus conventional transfemoral prostheses with respect to function, stumbles, and falls in an obstacle course (Seymour, et al). However, as with many studies, this report had major methodological flaws and the obstacle course data showed no physiologically or functionally significant difference between the microprocessor-controlled and non-microprocessor-controlled prostheses. Overall, the publications fail to establish that prostheses with microprocessor-controlled knees provide significant functional or health advantages for any specific patient population.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient has a long history of depression, anxiety, and multiple psychiatric hospitalizations.  She has been tried on Prozac and Cymbalta without success.  She has had augmentation, and was in DBT and CBT for more than adequate periods of time.  The records show that she improved with TMS treatment. The Health Plan denied the treatment based on the patients age, stating that TMS is contraindicated for individuals less than 22 years old.  However, per the U.S. Food and Drug Administration use of TMS may be available for treatment of those patients younger than 22 years old. The following is noted, labeling should include precautions for the use of rTMS devices in the treatment of patients with depressive or related conditions where safety and efficacy has not been established age less than 22.  The FDA approval for TMS therapy does not preclude those patients younger than age 22. Instead, FDA recommends the use of precaution when prescribing this therapy for patients who are younger than 21-years-old. 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 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 sixty-one year-old male with Peyronies disease is requesting authorization for verapamil.  Reviewers Findings:  The reviewing physician found that the peer-reviewed literature does not document the efficacy of topical therapy with verapamil.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lynparza (olaparib) for treatment of the enrollees ovarian cancer. Findings:  The physician reviewer found that the request for Lynparza (olaparib) is not medically necessary for treatment of the patients medical condition. Lynparza is U.S. Food and Drug Administration (FDA) approved for the treatment of adult patients with deleterious or suspected deleterious germline BRCA-mutated advanced ovarian cancer. There is no documentation demonstrating that the patient underwent genetic analysis or was negative. As such, the requested medication is not supported per FDA approved prescribing guidelines. For the reasons provided, treatment with Lynparza has not been established as medically necessary for treatment of the patients medical condition. 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 nternal medicine with sub-specialty certification in medical oncology 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 Cialis for treatment of the enrollees erectile dysfunction. Findings: The physician reviewer found there is support in the medical literature as well as in the documentation provided for the requested medication in this clinical setting. The patient has erectile dysfunction. Phosphodiesterase inhibitors including Cialis are considered standard first line therapy for management of patients with erectile dysfunction. Accordingly, Cialis would be considered a safe, effective and a standard of care for management of this patients medical condition. The records indicate that treatment with Cialis has been an effective regimen for this patient. Given these findings, Cialis is medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plan's denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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  denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90/400 mg for treatment of the enrollees medical condition. Findings: The physician reviewer found that according to the 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. In addition, the guidelines define acute hepatitis C as presenting within six months of the exposure with new rise in alanine aminotransferase (ALT) without alternative cause or low or fluctuating hepatitis C RNA values, which are not reported in this case. Even in suspected acute hepatitis C, the guidelines state that the provider and patient may elect to treat or to delay treatment initiation. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks is 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: Upheld

A 26-year-old female enrollee has requested authorization and coverage for a tonsillectomy for treatment of the enrollees tonsillitis.  Findings:  The physician reviewer found that based on review of the available records, this patient had only a few episodes of sore throat and hoarseness. There is no indication in the literature that bacterial tonsillitis can cause hoarseness. Hoarseness which occurs with sore throat is generally caused by a viral infection (Mau). In the medical literature, the indications for tonsillectomy do not include treatment of recurrent hoarseness (Clayburgh, et al). Therefore, in the absence of a diagnosis which is likely to be improved or relieved with surgical intervention, the requested tonsillectomy is not clinically indicated or medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a six-year-old male enrollee requested coverage of speech therapy for the treatment of speech delay.  The health plan denied the enrollees request indicating that speech therapy 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 speech therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested a microprocessor-controlled prosthetic leg for treatment of his right leg above the knee amputation.  Findings:  The physician reviewer found that the medical literature supports the functional benefits of microprocessor-controlled prosthetic knees for patients who are active community ambulators with transfemoral amputations (Hafner, et al; Seymour, et al). The patient is an appropriate candidate for this type of prosthesis given his age, functional status, and active lifestyle. The records do not describe any indication for delay in fabrication and fitting of the most appropriate prosthesis. In this patients case, a microprocessor-controlled prosthetic knee is consistent with current clinical standards of practice and medically necessary. It should enhance the patients gait, reduce fall risk, and reduce barriers to resuming the many facets of his active lifestyle. Consistent with these findings, the requested equipment is medically necessary for treatment of the patients medical condition.