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

A 46-year-old female enrollee has requested inpatient psychiatric hospital services for treatment of her behavioral health condition. Findings:  The physician reviewer found that considering the patients eating disordered behavior with secondary medical concerns and persistent depressive symptomatologies with suicidal ideation, acute hospitalization was initially medically indicated.  However, the medical records do not demonstrate the medical necessity of inpatient psychiatric hospital services.  During the hospitalization, the patient had steady weight loss.  She was eating three meals per day without snacking.  She was addressing her food related fears and concerns in therapy.   In terms of mood, the patient began an antidepressant shortly after admission, and a stimulant medication was added thereafter.  By the date indicated, the patients medication regimen was well-established in terms of dosing and tolerability.  The patient had ongoing distorted schemas and poor self-esteem, but she had no acute safety issues or behavioral disturbances on the unit.  Although suicidal ideation was endorsed in the psychiatric notes, there was no periodic risk assessment or comment on modifiable factors, or the suicidality itself.  In sum, the patients depression and eating habits were improving.  There was no evidence of an acute psychiatric syndrome.  It was no longer reasonably expected that the setting would further improve the patients condition or prevent a more serious episode of illness.  All told, inpatient psychiatric hospital services were not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested anti-reflux surgery using the LINX Reflux Management System for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. The documentation submitted for review indicates that the patient has not tried maximum acid suppression treatment. Until the patient fails optimized conventional oral medication or demonstrates intolerance or a contraindication to the same, there is no medically compelling reason for the requested service. All told, the anti-reflux surgery using the LINX Reflux Management System is not likely to be superior over other available treatment modalities.
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 breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities.  Digital breast tomosynthesis with [three-dimensional] 3D images might overcome some of the limitations of conventional [two-dimensional] 2D mammography for detection of breast cancer. Researchers investigated the effect of integrated 2D and 3D mammography in population breast cancer screening. It was concluded that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. As such, the digital breast tomosynthesis was likely to be more beneficial for breast cancer screening than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure 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 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: Upheld

A 54-year-old female enrollee has requested an osteochondral allograft for the treatment of her focal osteochondral lesion in the left knee.  Findings:  Two physician reviewers found that the patient is a 54-year-old female who seeks coverage for an osteochondral allograft of medial femoral condyle for suspected osteonecrosis. There is significant involvement of entire medial compartment of the knee. Allograft would not address involvement of medial tibial plateau. She is not an ideal candidate for an osteochondral allograft given her age and the tibial involvement. However, she is a good candidate for unicompartmental replacement.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested Lyrica for treatment of her radiculopathy.   Findings:  The physician reviewer found that the patient has a chronic pain syndrome and radiculopathy following spinal surgery. Presumably there are nocioceptive and neuropathic components to her pain. Alternative treatments including tricyclic antidepressants, anti-epileptic drugs and Cymbalta have been tried and were unsuccessful. There are no medications specifically approved for patients such as this one. Standard treatments have been sufficiently explored as well as invasive therapy with a spinal cord implant. Lyrica is approved for the treatment of diabetic peripheral neuropathy and post herpetic neuralgia. This medication is generally well tolerated and effective for these types of neuropathic pain. At this juncture, a trial of Lyrica is a reasonable clinical approach and likely to be beneficial in the management of the patients radiculopathy. If adequate dosages of Lyrica do not produce clinically significant improvement for this patient within two months, the trial should be discontinued.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the whole exome sequencing (WES) genetic testing. As noted in the medical literature, WES is a newly available technology whereby the portion of the genome consisting of coding sequences is analyzed for variants that may explain a patients phenotype. Clinical indications for WES are a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype. The utility of WES for gene discovery to identify the genetic cause of well-characterized specific phenotypes has been demonstrated in the current medical literature. The utility of WES in the clinical arena has been demonstrated to assist in diagnosis in approximately 25% of patients referred for testing. The majority of these patients had a neurological phenotype (intellectual disability), which is consistent with this patients presentation. Given these data, the WES genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in pediatrics and genetics and is actively practicing. One Reviewer is board certified in pediatrics and genetics and is actively practicing.  One Reviewer is board certified in pediatrics and genetics and is 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 reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees depression, anxiety, obsessive compulsive disorder (OCD), and suicidal ideation. Findings:  The physician reviewer found that shifting the frequency of therapy and/or treatment setting is common for patients with severe OCD and consistent with the American Psychiatric Association (APA) guideline recommendations. The APA noted that the appropriate treatment setting may be the hospital, a residential treatment or partial hospitalization program, home-based treatment, or outpatient care, while daily psychotherapy may be warranted in severe cases. Additionally, the diagnosis of clinical depression accompanies this patients OCD and anxiety. This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders are notoriously difficult to treat and in general have poorer outcomes. In accordance with modern psychiatric practice, this patient has pursued treatment in less restrictive settings during the episode of illness. However, she has failed both outpatient services and partial hospitalization program (PHP) levels of care. The patient has significant mood symptoms with suicidality. She has poor self-esteem, emotional dysregulation, anxiety, family strain and difficulty leaving the home. Her medications have not been optimized. RTC level of care has been recommended by the patients providers. In the absence of adequate treatment, the confluence of self-perceptions, clinical symptoms and cognitive schemas place the patient at risk for an untoward outcome and an unnecessarily heightened risk for self-harm. As such, a premature discharge would result in undue patient morbidity and prompt re-admission, possibly to a higher level of care. Thus, treatment at the residential level of care is safe, appropriate and consistent with current medical guidelines. Final Result: The reviewer determined that the services at issue were and 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested skilled nursing facility services for treatment of his medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for skilled nursing facility services has not been established. In this case, the patient was functioning at a high level in physical therapy. Further intensive skilled physical therapy services, at the skilled nursing facility level, were not medically necessary at that time. He did not show a need for speech therapy or skilled nursing services. His functional level for self-cares was not described in detail. Overall he showed progress on occupational therapy throughout his stay. For the reasons provided, the skilled nursing facility services in question were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested a CT angiography for an evaluation of her cardiac condition. Findings:  Three physician reviewers found that there are guidelines published from the American College of Cardiology (ACC) regarding the appropriate use of cardiac CTA. In this case, the patient has had prior testing which was abnormal. Her prior stress echocardiogram was described as abnormal rather than equivocal. She does not meet the guidelines for cardiac CTA. In this case, her prior testing was abnormal and the next clinical step would be a clinical decision to treat her atypical chest pain or even silent coronary artery disease with aggressive medical intervention, or a decision to proceed with diagnostic cardiac catheterizations towards revascularization. The ACC guidelines do not, as yet, recommend cardiac CTA as an intermediate step prior to cardiac catheterization after abnormal stress testing. The ACC guidelines recommend CTA as appropriate after equivocal prior stress testing in symptomatic patients with chest pain, rather than CTA as an intermediate step to confirm prior abnormal stress testing.
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. The addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, 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: Overturned

A 46-year-old female enrollee has requested for continued use of morphine for treatment of her multiple sclerosis and degenerative joint disease (DJD).  Findings:  The physician reviewer found that the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) states that, for a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors hesitate to prescribe them for long-term use because of the potential that the person taking them will become physically or psychologically dependent on them.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's 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: The patient has requested authorization and coverage for breast augmentation. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, Non-genital surgical procedures notably breast augmentation are often of greater practical significance in the patients daily life than reconstruction of the genitals. These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The WPATH further noted that, other surgeries for assisting in body feminization include Breast/chest surgery: augmentation mammoplasty (implants/lipofilling). The records provided for review report that this patient has gender dysphoria related to her breasts and her providers have recommended breast augmentation to address her gender dysphoria. The available documentation supports that the patient is likely benefit from surgery as a treatment for her gender dysphoria. Moreover, the requested procedure is in accordance with the generally accepted standards of mental health and substance use disorder care, and clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the requested breast augmentation 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 psychiatry with expertise in transgender health 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: An enrollee has requested authorization and coverage for QNASL 80 mcg for treatment of her chronic sinusitis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Reviews comparing steroid based nasal sprays indicate that there is no difference in efficacy between them.  The differences found are in patient preference and safety during pregnancy. QNASL has not been found to be more efficacious than the Health Plans standard therapy available on the formulary. 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 otolaryngology 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 8 weeks for treatment of her hepatitis C.   Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this patients case.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The guidelines recommended urgent initiation of treatment for patients with advanced fibrosis or compensated cirrhosis.  Early initiation of treatment may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.  All told, Harvoni for eight weeks is medically indicated for the treatment of this patient.  Final Result:  Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: Upheld

A 49-year-old female enrollee has requested bladder stimulation treatment (percutaneous tibial nerve stimulation) for treatment of her urinary incontinence. Findings:  Two physician reviewers found that the services at issue were not likely to be more effective for this patient than other available options. According to the literature review by Monga and colleagues, long-term follow-up data to validate the sustained benefit of PTNS in the treatment of lower urinary tract symptoms are lacking. The medical literature in regards to PTNS in this clinical setting remains controversial, and there are a variety of treatment that are readily available and that have wide acceptance as to the efficacy. Therefore the services at issue were not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old man who is requesting coverage for continuation of growth hormone (GH) treatment to prevent a heart attack. He has been taking growth hormone therapy for three and a half years. The medical records from his endocrinologist from the 2003 to 2004 time period do not list or substantiate a diagnosis of panhypopituitarism. Pituitary function test results are not included in the submitted documentation.  The patient is being treated for diabetes mellitus type 2 and dyslipidemia. He has a normal total testosterone and above normal levels of IGF-1. Based on the information provided, it does not appear the patient is on any other pituitary tropic hormone replacement. At issue is whether continued growth hormone therapy is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no evidence of GH deficiency or any other pituitary dysfunction to sustain a diagnosis of panhypopituitarism in this patient. Patients who have documented adult growth hormone deficiency (AGHD) have an increased incidence of coronary artery disease and increased mortality. However, the use of GH to prevent an acute coronary event in patients without a diagnosis of AGHD is not the standard of care. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.