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

A 32-year-old male enrollee has requested a subcutaneous mastectomy for treatment of his gynecomastia. Findings:  The physician reviewer found that lipomas are localized over growths of fat into a separate mass or benign tumor from surrounding soft tissue. They are benign but can cause problems if they grow to a sufficient size to compress adjacent structures such as nerves or arteries. The vast majority of lipomas are so close to the skin surface that they will never cause a problem other than a cosmetic problem and therefore their removal is not medically necessary. The only other exception to their removal being cosmetic is if the physician suspected a malignant process and was removing the mass for biopsy. That is unlikely when the lipoma has been present for many years and is not accompanied by lymphadenopathy or skin changes, as is the case with this patient. Thus, the submitted documentation does not support the medical necessity of subcutaneous mastectomy.  With regard to whether the requested procedure is reconstructive in nature, the proposed surgery will not improve function and is not required to create a normal appearance from an abnormal appearance. Based on the documentation provided, the degree of breast enlargement is not severe and is reportedly visible only in certain positions. As such, the proposed surgery will not offer more than a minimal improvement in the appearance of the patient.
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:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services, physical therapy and gait training services prior to discharge, and a new pair of diabetic shoes and inserts. This patient does not require SNF services with the specialized skill, knowledge and judgment of a skilled professional nurse for safe and effective treatment. The patient does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Her medical conditions are chronic and stable. Similarly, the patients functional level does not require physical therapy services with the specialized skill, knowledge and judgment of a specialist. The patient has undergone prior gait training and has been able to ambulate with restorative nursing. A right foot x-ray ruled-out a definite acute bony fracture. For these reasons, SNF services including physical therapy and gait training services are not medically necessary for treatment of this patient. With regard to the requested diabetics shoes and inserts, the records document that the patient was provided a new pair of shoes. The records do not include documentation of a follow-up evaluation to determine whether she needs new shoes and/or inserts as the patient states she still has foot pain. The records do not state that the provider performed this fitting. Prior documentation from the Hangar Clinic do not reveal that the patient required new shoes, but rather recommended a gradual wearing period to break in her new shoes. Without evidence of a new evaluation and fitting, another pair of new shoes and new inserts are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services and equipment 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 with subspecialty certification in neuromuscular 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: Upheld

A 60-year-old male enrollee requested authorization and coverage of a color Doppler ultrasound. The Health Plan denied the request indicating that the requested services are not medically necessary for the evaluation of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female has requested gastric bypass revision surgery for treatment of her morbid obesity.  Findings:  Two physician reviewers found that the patient presents with a history of morbid obesity.  She was evaluated for bariatric surgery eleven years ago and was deemed to be an appropriate candidate for Roux-en-Y gastric bypass surgery.  Her preoperative weight was 270 pounds.  There are discrepancies in the medical records regarding the patients height.  Roux-en-Y gastric bypass surgery was performed following her evaluation.  One year later, the medical records noted that the patient weighed 192 pounds, with a body mass index (BMI) of 32.  The patient has subsequently regained weight.  Current medical records note a weight of 337.4 pounds and BMI of 52.8.  The documentation notes poor nutrition habits.  This patient underwent Roux-en-Y gastric bypass eleven years ago.  Within eleven months, the patient lost 78 pounds.  Based upon the submitted documentation, the first surgery provided excellent control of her morbid obesity.  The current weight gain is not due to a failure of the surgical procedure.  Per the medical records, the patient has poor nutrition habits which are likely to prevent postoperative loss of excess body weight.  Based upon the current medical literature, revisional surgery is less likely to be as successful as the primary operation, especially when the indication is weight regain.  The submitted documentation fails to demonstrate the superior effectiveness of the requested surgery in this patients case.  This patient underwent a dietary evaluation which suggested poor dietary habits.  The medical records do not indicate a complication of the prior Roux-en-Y gastric bypass surgery.  There is a lack of proven benefit from pouch reduction or outlet reduction in this clinical setting.  In this case, maximization of dietary efforts and increased exercise were appropriately recommended.  In sum, the requested gastric bypass revision surgery is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Estrogel for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  This patient has severe menopausal symptoms.  She indicates that she had adverse effects from oral estrogen and when she tried the estradiol patch.  The current medical evidence supports the requested medication in this clinical setting.  The treatment with transdermal estrogen gel is an appropriate option for this patient, and potentially safer than oral therapy.  The Health Plan requires that the patient try and fail an oral option and an estrogen patch prior to approval of Estrogel.  It appears that she meets this criteria.  In addition, she has used the Estrogel with good results.  In sum, Estrogel gel is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications:  The reviewer   is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz tablets. Findings: The records provided for review document that this patients symptoms of alopecia were present for one year before they presented to their provider for treatment. The patient underwent evaluation and skin biopsy, which support a diagnosis of alopecia totalis given the facial involvement. During the past year, they have been treated with intralesional Kenalog, intramuscular steroids, as well as anthralin and squaric acid without sustained improvement. They have experienced recurrences in areas after initial response to treatment. The patients provider has recommended treatment with Xeljanz. In the medical literature, a study reported that Xeljanz was more effective than immunotherapy including squaric and anthralin, as well as traditional systemic therapy with a lower risk profile. Given that this patient has undergone treatment with intralesional and intramuscular steroids in addition to immunotherapy, and still has persistent disease diagnosed as alopecia totalis, Xeljanz is appropriate. Further studies support Xeljanz as safe and effective a treatment for alopecia areata, especially in cases that are not responding to typical treatments. For these reasons, the requested Xeljanz tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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: Urgent Care
Decision: Upheld

A 49-year-old female enrollee has requested for emergency services for treatment of her migraine headache.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine, a history of migraine and 5/10 headache pain for one month, would not reasonably expect the absence of emergency care to jeopardize their health. The patients symptoms as documented on the medical record were not of acute onset or sufficient severity to warrant emergency evaluation. The patient could have been safely evaluated on a non-emergency basis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested genetic mapping test for evaluation of his cholangiocarcinoma stage IVA.  Findings:  Two physician reviewers found that according to the medical records submitted for review, the testing in dispute was not likely to be more beneficial for this patients medical condition than other alternatives. There is a lack of rationale as to how the results of the assay would influence his treatment management. Moreover, pharmacogenic analyses at this time are not considered the standard of care in the management of gastrointestinal cancer. As such, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested continuation of frequency of direct applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Orinstein and colleagues found that children with optimal outcome from the ASD started ABA at an earlier age of 4-5 and were receiving 25 hours per week of therapy compared with 18 hours per week for those with high functioning autism. ABA services are medically indicated for treatment of the patients autism spectrum disorder. The patient has received high level ABA since 2012 which have been effective for some skills including communication, executive functions and adaptive skills. However, he continues to have elopement issues and frequent stereotypy. A significant decrease in ABA services often leads to a return of previously addressed maladaptive behaviors and slowing of progress. Therefore, a portion of the per week requested direct ABA and supervision is medically necessary for this patient.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees degenerative disc disease. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three CHDR physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of your medical condition than any available standard therapy. Because all three CHDR physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been Upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of his chronic hepatitis C virus genotype 1b.  The physician reviewer found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. Per the guidelines, non-cirrhotic genotype 1b patients should be treated with Viekira Pak for 12 weeks whether they are treatment-naive or have failed therapy with interferon and ribavirin. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak for 12 weeks is supported as 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to nonliver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi/Daklinza for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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: Overturned

A 59-year-old female enrollee has requested a dual energy x-ray absorptiometry (DEXA) scan for an evaluation of her osteopenia. Findings:  The physician reviewer found that even if this patient only has osteopenia at this time, the progression to osteoporosis can be prevented and risk for fracture decreased with the proper evaluation and pharmacological treatment. It is a good standard of care in the United States to order a DEXA scan in a postmenopausal woman with risk factors of osteoporosis. It is the gold standard among physicians who treat patients with osteoporosis to order a baseline bone density study at the onset of menopause and then order follow up scans to determine any progression into osteopenia.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage for a bone growth stimulator for the treatment of Osteoporosis.  The health plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-five year-old male diagnosed with metastatic colon cancer is requesting authorization for the use of Erbitux.  The patient was initially treated with a number of procedures and there was reduction of liver tumors seen on a CT scan.  However, another CT scan revealed progression of metastatic disease.  The patient was then treated with Erbitux and Camptosar (CPT-11).Reviewers Findings:The reviewing physician found that the submitted medical records do not clearly document that the patient was treated with CPT-11 alone prior to the initiation of Erbitux. Thus, based on the information provided it is not clear that the use of Erbitux in this setting is within clinical guidelines. Therefore, the reviewing physician found that the Health Plan denial should be upheld
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested intravitreal Lucentis injections for the treatment of his macular edema. Findings:  Three physician reviewers found that this patient has vision in only one eye. He has been receiving intravitreal Lucentis injections from a retinal specialist who feels they are warranted due to the decreasing vision in his only seeing eye. The Health Plan has denied coverage for intravitreal Lucentis injections, and this is the subject of the appeal. Lucentis has shown effectiveness in treating macular edema in other conditions aside from its original role in the wet phase of age-related macular degeneration. Based on its use in other settings, it is medically reasonable to pursue this line of therapy for the patient due to his monocular status and lack of alternative therapies for treatment of his progressive condition. There is no evidence that any other therapy will have superior efficacy in this patient who will lose his remaining vision without effective treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested oxycodone for the treatment of his medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, the medical necessity for oxycodone has not been established. The patient presents with low back pain and chronic abdominal pain complicated by previous gastric surgery with notable use of high-dose oxycodone. The pain management note documents that that it would not be in the patients best interest to continue high-dose opioid pain medications. In this clinical setting the recommendation by the Health Plan for treatment in a chemical dependency program is medically reasonable and appropriate. Given the above, the requested oxycodone is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that 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 anesthesiology with sub-certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.