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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested autologous fat grafts to right lateral thigh, implantation of biologic implant for soft tissue reinforcement, and suction assisted lipectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient was noted to have a hematoma following a fall.  She is reported to have soft tissue changes and dimpling as a result.  The area of the thigh represents an abnormal occurrence of soft tissue changes and dimpling as the result of trauma.  There is no evidence that the requesting surgery of fat grafting is being done to improve function.  The aim is to correct contour defects, which would be in an attempt to create a more normal appearance.  However, the degree of severity of the condition is not adequately defined in the medical documentation.  The photographs do not show that there is a significant condition present.  Thus, without the degree of severity clearly defined and with photographs that do not show a significant defect, the fat grafting would not likely provide more than a minimal improvement in the appearance.  All told, the requested services are not medically necessary and are not reconstructive in nature.  Final Result: The reviewer determined that the requested services are not reconstructive in nature 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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 and the Infectious Diseases Society of America, 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.  Per the 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.  For these reasons, the requested treatment with Harvoni 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 35-year-old female enrollee requested authorization and coverage of intravenous immunoglobulin (IVIG) therapy for the treatment of conditions that have resulted from toxic mold exposure.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-month-old male enrollee, born prematurely at 33 weeks gestation, has requested authorization for two additional Synagis injections. Findings: The physician reviewer found that according to the American Academy of Pediatrics, palivizumab prophylaxis should continue for the duration of the RSV season, with the first dose typically administered in November and the final dose administered in March to provide coverage into April. Dosing is recommended every 30 days, as the half-life of palivizumab is approximately 24 days. Although the criteria for determining the end of the RSV season is flexible, one of the more strict definitions is a positive testing rate below 10%. Some experts hold that any positive tests in a given area pose a significant risk to susceptible children. While protection through the month of April would have been medically appropriate, there is no clinical benefit in a sixth or seventh dose of palivizumab at the present time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cryoablation for treatment of her medical condition.   Findings:  Two physician reviewers found that several multi-institutional trials have demonstrated cryoablation to be a successful option for the resolution of fibroadenomas without surgical excision. The U.S. Food and Drug Administration (FDA) has approved the use of cryoablation as a safe and effective therapy for fibroadenomas. Results of cryoablation have been followed out to four years and demonstrate the procedure to be safe, efficacious, and durable.  Cryoablation offers an alternative to surgical excision of benign fibroadenomas.  Due to the analgesic effect of cold temperatures, the procedure is virtually painless to the awake patient, and can be performed safely in the office with no sutures and little to no scarring.  All told, the requested cryoablation is likely to be superior over other treatment options.  Final Result: Two reviewers determined that the requested services are 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing   Two reviewers are board certified in surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injection. 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 from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine 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 patient has a history of lasting benefit from viscosupplementation with Monovisc injections with excellent results. The patient did not adequately respond to treatment with physical therapy or NSAIDs. The provider has recommended a repeat injection of Monovisc into the right knee. In this clinical setting, the medical literature supports treatment with viscosupplementation for this patient. Accordingly, the requested Monovisc injection is 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Premarin 1.25 mg a day. Based on current recommendations from the North American Menopause Society (NAMS), estrogen replacement may be continued beyond age 65 with the proper monitoring and review of risks and benefits. The NAMS position statement notes that hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The documentation provided for review indicates that this patient requires immediate management and control of her blood pressure. Once under control with a systolic blood pressure under 150, the patient may be started on Premarin, but at a dose not higher than 0.625 mg per day. Given these findings, the requested Premarin 1.25 mg a day is 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 diabetes, endocrinology and metabolism 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

An 18-year-old female has requested coverage for partial hospitalization level of care for the treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  In this clinical setting, treatment at the partial hospitalization level of care is medically indicated.  As noted by the American Psychiatric Association, the determination regarding appropriate level of care is based upon overall physical condition, psychology, behaviors, and social circumstances.  In this patients case, she had not consolidated the treatment gains necessary in the intensive outpatient setting.  Per the clinical documentation, her condition was likely to worsen without appropriate treatment.  The current medical evidence and clinical guidelines support partial hospitalization level of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee has requested left anterior lumbar interbody fusion at L5-S1 for treatment of his degenerative disc disease of the lumbosacral spine.  Findings:  The physician reviewer found that this patients records do not document that conservative measures have been exhausted. Given the absence of attempts at conservative therapies and lack of clinical findings indicative of fusion, the requested surgery has not been demonstrated to be medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested for speech therapy for treatment of the enrollees severe receptive and expressive language delays. Findings:  The physician reviewer found that according to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  The current medical evidence supports the requested therapy in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee has requested for the medication Zometa for treatment of his osteoarthritis and osteoporosis.   Findings:  The physician reviewer found that there is recent relevant peer-reviewed scientific literature proving the efficacy of Zometa for this type of patient, and specifically for the stated indication. As such, the use of Zometa was medically appropriate in this case and should be continued.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old male who has a history of obesity. His current weight is 260 pounds. His provider indicates he has central obesity and gynecomastia. The patient has requested authorization and coverage for liposuction of the breast area. The Health Plan has denied this request indicating the requested procedure is considered a cosmetic procedure.The patient has requested liposuction for treatment of gynecomastia. Liposuction alone has not been demonstrated as an effective treatment for male gynecomastia. In addition, based upon the information provided, the patient does not meet medical necessity criteria for reduction mammaplasty for treatment of gynecomastia. There is no evidence the patients condition has been unresponsive to conservative treatment. 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for emergency medical services.Findings:  The physician reviewer found that the psychiatric services provided were not necessary for treatment of a psychiatric emergency medical condition. The patients post-acute withdrawal symptoms were mild to moderate. The patient was not a danger to self or others, and the patient displayed no self-harming behaviors. There were no emotional, behavioral, cognitive, or impulsive symptoms that supported a psychiatric emergency medical condition. The patient had no comorbid medical conditions, and was psychiatrically stable. The patient was not manic or psychotic. The patient was assessed as a mild safety risk. The patient was motivated and actively engaged in working the program. The patient was developing insight and coping skills. The patient had no acute symptoms placing the patients health in jeopardy, causing impairment, or serious dysfunction. The patient had no psychiatric emergency medical condition as the patient was not a danger to self or others. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue. FFinal Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. 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

The patient has requested authorization and coverage for Novolog 100 Units/mL FlexPen. Strict glucose control using multiple doses of insulin is the standard treatment for insulin dependent diabetes mellitus. Recent findings from clinical trials suggest that insulin lispro, insulin aspart, and insulin glulisine are equally safe and efficacious. The records provided for review do not demonstrate that treatment with Admelog has been ineffective to support an indication for Novolog. Based on the available documentation, the requested Novolog 100 Units/mL FlexPen is 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 diabetes, endocrinology, and metabolism 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

The patient has requested reimbursement for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the RTC level of care services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implant neuroelectrodes for treatment of the enrollees lumbar radiculopathy and spondylosis. Findings:  Two physician reviewers found that the use of spinal cord stimulation with implant neuroelectrodes is not considered a first-line therapy. Further, this type of treatment is not recommended prior to evaluation with a thorough psychological evaluation. A preoperative psychological evaluation has been used to predict the successful outcome of spinal cord stimulation. This patients records do not include documentation of surgical or psychological evaluations to determine whether she is an appropriate candidate for the requested procedure. Final Result: The reviewers determined that the service 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 anesthesiology with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/ Case Summary:  The patient has Crohns Disease of the large and small bowel.  Her symptoms include loose stool with intermittent streaks of blood, abdominal bloating, gassiness, nausea, and constipation, in between flare-ups.  She is followed by a gastroenterologist and has tried and failed oral steroids, as well as oral and rectal mesalamines, and Linzess.  She also tried Remicade, which resulted in some mucosal healing, but she developed a drug reaction and psoriasis, so she is unable to take any other anti-tumor necrosis factor medications. The medication was then changed to intravenous (IV) infusion of Stelara, with which she did well, but continued to have gastrointestinal inflammation on the standard eight week dosing.  She has elevated calprotectin levels and a colonoscopy showed some new inflammation. Due to this and increasing calprotectin levels, her physician is now recommending that her Stelara injections be increased to every four weeks to achieve the same degree of clinical, lab, and endoscopic remission that was seen initially. The health plan denied the injection of Stelara 90mg/ml at a dosing of every four weeks as not medically necessary. They indicate the use of Stelara every four weeks as maintenance is not supported or appropriate, and that there is no literature support or FDA indication for the use of Stelara at a dosing of every four weeks. The medical literature indicates that in  a cohort of patients studied to determine the relationship between trough levels of ustekinumab (Stelara), and clinical response during the maintenance phase, patients received 90 mg every four or eight weeks.  A recent presentation of data was in regard to optimization of Stelara to recapture response. The study analyzed patients with active Crohns disease who had their dose escalated from 90 mg every eight weeks to 90 mg every four weeks because of loss of response or inadequate response.   More than half the patients recaptured response after optimization. Therefore, based on very recent data, it has been shown that shortening the interval to four weeks has been used to optimize efficacy of Stelara. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.