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

The patient has requested authorization and coverage for treatment by a pulmonary specialist, a breathing machine and oxygen, cough syrup with codeine, Albuterol solutions for the enrollees nebulizer, and Ventolin HFA  mg inhaler #18. The records provided for review document that the patients complaints include a cough, but there is no notation of other pulmonary complaints. The records report that the patient is a smoker, so she may require treatment with some of the requested medications. However, the records do not include a recent pulmonary function test (PFT) to support a current indication for the requested medications. Evaluation by a pulmonary specialist can help rule out smoking-related lung disease and determine whether the requested breathing machine and oxygen, cough syrup with codeine, Albuterol  solutions for her nebulizer and Ventolin HFA inhaler are indicated. Given these findings, the requested treatment by a pulmonary specialist is medically necessary, while the breathing machine and oxygen, cough syrup with codeine, Albuterol solutions for the patients nebulizer, and Ventolin HFA inhaler #18 are not supported as medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in pulmonary 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Hymovis injections in both knees. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the guidelines do not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited, and they have failed conservative treatment consisting of physical therapy with and strengthening exercises and NSAIDs. Given these findings, the requested Hymovis injections in both knees are medically necessary for 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 reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
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 the American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages this new technique brings to radiologists in the interpretation of mammograms. The advantages the technique offers relates to the tomographic nature of tomosynthesis which helps radiologists differentiate dense glandular tissue from architectural distortion which in turn decreases callbacks and increases detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only. In sum, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of her medical condition. Findings:  Two physician reviewers found that radiofrequency neurolysis was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain, due to facet pathology as long as the patients are appropriately selected. In reviewing the medical records, there is documentation of failed conservative therapy as well as previous positive response to lumbar facet radiofrequency which provided significant reduction in pain over a good number of months. Therefore, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were 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:   All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene tests (81211 - BRCA1 and BRCA2; 81213 - BRCA1 and BRCA2; 81479 - BART test) for evaluation of the enrollee, who has a family history of cancer.Findings:  All three reviewers found that there is sufficient support for the services at issue in this patients case.  In women with no personal history of breast cancer, the guidelines support BRCA testing for patients with two or more close relatives with breast cancer, one of whom was diagnosed at the age of 50 or younger.  Thus, the medical evidence supports BRCA testing in this clinical setting.  BART is now included automatically when BRCA testing is done. Final Result: Three reviewers determined that the testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acthar Gel for treatment of the enrollees scleritis.  Findings:  The physician reviewers found that scleritis is inflammation of the sclera, the wall of the eye, and is frequently associated with the rheumatologic/autoimmune spectrum of diseases. It generally presents with significant pain, and can result in severe vision-threatening problems if left untreated. The first line of treatment for uveitis is nonsteroidal anti-inflammatory drugs.  The second line of treatment is steroids. Unfortunately, treatment with steroids is not without the risk of side effects such as glaucoma and cataracts, as well as serious systemic side effects.  This patient has failed to respond to both. If the scleritis cannot be controlled adequately and safely with steroids, the third line of treatment is a disease-modifying antirheumatic drug, such as methotrexate. Disease-modifying antirheumatic drugs also carry the risk of serious side effects.  This patient has also been treated with methotrexate, and her scleritis is still not controlled. When steroids and disease-modifying antirheumatic drugs are unable to control the disease process, the fourth line of treatment is use of a tumor necrosis factor inhibitor, such as Remicade or Humira. In this patients case, her disease has not been controlled even with the addition of Remicade. She requires additional treatment in an attempt to bring her condition under control. There is sufficient support for the requested medication in this patients case. Thus, the requested Acthar Gel is likely to be of greater benefit than other options for treating this patient. Final Result: Two of three reviewers determined that the requested medication is 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 number one, two, and three are board certified in ophthalmology and 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: Upheld

A 38-year-old female enrollee requested authorization and coverage of the prescription medication Vioxx for treatment of back pain.  The enrollees health plan denied the request indicating that the requested treatment 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 prescription is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne gene test for evaluation of the enrollees thymic carcinoma.  Findings: Three physician reviewers found that the FoundationOne gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to Lamarca and colleagues Thymic malignancies are extremely rare although usually affect young adults and continue to remain an important health problem. Like other rare diseases, progress in thymic malignancies has been slow and the treatment cornerstone still remains surgical resection. Next generation sequencing and other advances in molecular biology are shedding light onto the multiple genetic aberrations involved and have opened a new field for research with molecularly targeted therapies such as CKIT inhibitors or anti-EGFR therapies. A study by Von Hoff and colleagues of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to where the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors and results from molecular profiling offer a rational selection of the next regimen. Therefore, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld

The parent of an eight-year-old male enrollee has requested  for acute inpatient psychiatric treatment for treatment of the enrollees autism and depressive symptoms. Findings:  The physician reviewer found that the documentation does not describe the patient as suicidal, homicidal, manic, psychotic, a danger to himself or others, unable to care for himself, or, as having an Axis III condition that required acute, 24-hour skilled and supervised nursing care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90/400 mg for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Thus, Harvoni 90/400 mg is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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: Experimental/Investigational
Decision: Overturned

The parent of a one-year-old female enrollee has requested Synagis injections for treatment of the enrollees risk of contracting respiratory syncytial virus.   Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from RSV disease in prematurely born infants, up to 12 months of age. The most striking of these complications is a birth weight of less than 2500 grams. Further, Holman and colleagues caution that an infant with a birth weight less than 1500 grams is 25 times more likely to develop complications with the RSV infection than an infant with a birth weight greater than 2500 grams. Despite the fact that this ex-premature female infant does not meet the criteria as set forth in the American Academy of Pediatrics (AAP) guidelines for Synagis administration, she is at risk for severe disease based on her family history of asthma and low birth weight. Further, there are currently no treatments currently available for the RSV infection, thus the only available prophylaxis is Synagis, which is likely to be more beneficial for prevention of this infection than the standard alternative of no vaccination.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of an Empi 6000 TENS unit (Empi 6000) for the treatment of back pain.  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 upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees chronic migraine and occipital neuralgia.  Findings:  Two physician reviewers found that the patient has documented migraine headaches with a frequency of more than 15 headache days per month and occipital neuralgia. In the past, the patient has failed multiple abortive and preventative medications for her headaches including Topamax, Elavil, Inderal, Maxalt, and Imitrex. Her headache specialist has recommended a trial of Botox to help reduce her headaches. The patients request for coverage for Botox injections was denied by the Health Plan as investigational. The patients treating provider reports that this patient has been treated with Botox for about eight years with substantial relief in her migraine symptoms. Since the patient has tried and failed treatment with multiple preventive and abortive agents in the past, treatment with Botox is likely to be more beneficial than standard alternatives. In addition, Botox is now FDA approved for treatment of patients with this patients clinical history and presentation and supported in the clinical trials as safe and effective. Accordingly, the use of Botox should be approved for this patients refractory migraines.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested monthly treatment with intravenous immunoglobulin (IVIG) for the treatment of her common variable immune deficiency (CVID). Findings:  The physician reviewer found that the history as presented by the requesting physician and the documents submitted are not sufficient to justify the use of IVIG. Although the patient appears to have a blunted immunological response to pneumococcal antigens, it is not known if  she was prescribed systemic steroids over the past few years. If so, this could account for the blunted response as well as the borderline low IgG. In any case, there is evidence of a response, thus the patient is not a non-responder. Given the borderline low IgG, lack of response should be a prerequisite for the use of IVIG. Lastly, the immune response to pneumococcal antigens resides in IgG subclass 2, and this value is normal.
Appeal type: Medical Necessity
Decision: Upheld

This is a 45-year-old female patient who is postoperative from a gastric bypass procedure.  She is now facing the problem of excess skin following substantial weight loss. She was evaluated by two plastic surgeons and was advised to undergo panniculectomy to relieve her intertrigo. This procedure was authorized and scheduled, but the patient has requested that body contouring (abdominoplasty) be performed at the same time as the panniculectomy. The Health Plan denied authorization for the abdominoplasty based upon a determination that it is not medically necessary.Upon review of the submitted documentation, there appears to be a functional indication for a panniculectomy. However, there is no documentation of a functional problem or medical condition related to the excess abdominal skin. The abdominoplasty desired by the patient is a cosmetic procedure, and therefore is not medically warranted for treatment of her condition. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for bilateral mastectomy and nipple reconstruction. The submitted documentation supports the medical necessity of the requested services in this clinical setting. This patient has persistent gender dysphoria and has found continuing binding untenable in the long-term. The Health Plan noted that gender reassignment surgery may be necessary for patients who are at least 18 years of age. However, this minimum age is arbitrary, and does not reflect that this surgery is often necessary for transgender male teenagers to be able to socially transition and lead a normal adolescence. The World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People states that chest surgery under these circumstances is often necessary in patients under 18, particularly those who have extended periods of social transition and have started testosterone. Chest surgery for transgender male teenagers has been demonstrated to be an effective treatment for gender dysphoria in minors with persistent gender dysphoria. Prolonged chest binding can have negative health consequences, and it is not a reasonable alternative for this patient to bind his chest until he is 18 years of age. Approximating a male nipple, in size and placement, is part of establishing a normal appearing male chest, which is part of the medically necessary treatment of gender dysphoria. All told, the requested bilateral mastectomy and nipple reconstruction are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Gammagard intravenous infusions. The records provided for review do not support a diagnosis of Lyme disease or Powassan disease in this patient. The positive serological testing that is represents likely cross-reactions with other antigens given the lack of clinical signs and symptoms reported in the patients chart. There is a lack of documentation to support a tick-borne illness. As noted by the Centers for Disease Control and Prevention (CDC), Powassan disease confirmation is required to make a diagnosis, which is not present in the records provided for review. Accordingly, the requested Gammagard intravenous infusions are not medically necessary for 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 with subspecialty certification in infectious 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.