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

A 55-year-old male enrollee has requested transthoracic echocardiography, complete, with spectral Doppler echocardiography, or color flow Doppler echocardiography (CPT code 93307) for evaluation of his status post mitral valve repair.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this patients case.  This patient is status post mitral valve repair.  Per the clinical records, there are no current cardiac symptoms, and recent physical examinations did not reveal murmur.  An echocardiogram last year reportedly demonstrated normal valvular function.  In this circumstance of a clinically stable patient without objective evidence of significant residual mitral regurgitation on recent echocardiogram, a repeat echocardiography is not medically necessary.  Current guidelines do not support the requested services in this clinical setting.  All told, the medical necessity of transthoracic echocardiography, complete, with spectral Doppler echocardiography, or color flow Doppler echocardiography (CPT code 93307) has not been demonstrated.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 50-year-old female with symptomatic macromastia who complains of back, shoulder and neck pain.  The photographs provided in the record show moderately large, ptotic breasts. Her provider has requested authorization for the excision of 400 grams of tissue from each breast. The Health Plan denied the request based upon a determination that the procedure is not medically necessary.The patients complaints of back, shoulder and neck pain are consistent with a diagnosis of symptomatic macromastia and the photographs confirm that she has larger sized breasts.  However, the planned resection of 400 grams per breast is quite small and may not correct her symptoms. The Schnur study found that resection weights above the 22nd percentile indicated that the patients motivation was purely medical.  The planned resection of 400 grams for this patient is below the 5th percentile guideline of 401 grams.  While the question of what volume of resection is adequate to correct a patients symptoms remains controversial, the Schnur data indicates that if the planned reduction is too small, the procedure should be considered cosmetic. This patient does have functional complaints and it seems that her motivation is not cosmetic.  However, the proposed reduction is likely to be too small to correct her symptoms. This patients BSA, according to the Schnur data, would require a breast reduction of at least 628 grams to be considered medically necessary.  Therefore, a breast reduction of 400 grams per breast would not be considered medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old male enrollee has requested for acute inpatient hospital services for treatment of his seizure disorder. Findings:  The physician reviewer found that there are no records to support continued acute hospitalization.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested a consultation for a hip resurfacing procedure for the treatment of his osteoarthritis. Findings:  The physician reviewer found that hip resurfacing is a new procedure that is as good as total hip arthroplasty, but it does not have documented reliable improvement over the traditional total hip arthroplasty. The two papers reviewed highlight the disagreement among orthopedic surgeons on this issue. That being said, it is medically appropriate to allow the patient to consult another orthopedic surgeon in order to ensure he is aware of all treatment options and makes an informed decision regarding his treatment. A consultation for a hip resurfacing procedure is medically reasonable and indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to remove the enrollees Lap-band.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the submitted documentation, the patient desires removal of the Lap-band and conversion to sleeve gastrectomy.  However, there is no documentation of a dietary evaluation or an updated psychological evaluation to support that this patient is an appropriate candidate for revisional surgery.  Just as with primary bariatric surgery, the completion of an updated multidisciplinary evaluation is necessary to determine if this patient would be an appropriate candidate for bariatric surgery.  In this patients case, there is no specific anatomic or technical complication to justify removal of the Lap-band at this time.  All told, the requested surgery to remove the patients Lap-band is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in 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: Upheld

A 62-year-old male enrollee has requested for a functional electrical stimulator (FES) Bioness L300 for treatment of his foot drop secondary to multiple sclerosis. Findings:  Three physician reviewers found that functional electrical stimulation is used to prevent or reverse muscular atrophy or electronically provide function in a paralyzed/paretic limb. It has been used for some time in the setting of stroke and spinal cord injury and more recently, has been proposed for patients with multiple sclerosis. The 2008 publication by Stein cited above, studied functional electrical stimulation in patients with non-progressive conditions (e.g., stroke) and progressive conditions (e.g., multiple sclerosis) of the central nervous system. The authors found that in non-progressive conditions, therapeutic increases were seen up to at least 11 months of use. However, the authors noted that in progressive disorders such as multiple sclerosis, the progression of the disease eventually overcomes the early therapeutic effects. At this time, the use of a functional electrical stimulator such as the Bioness L300 has not been shown to be more beneficial than usual and customary care (the use of an ankle foot orthosis) for patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3 criteria for RTC 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. As the patient has met the six ASAM dimensions, 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: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female who is status post gastric bypass for morbid obesity. The patient reports having lost 150 pounds. She underwent bilateral reduction mammaplasty for symptoms of back, neck, and shoulder pain in 2004 but she still requires narcotics three to four times per day. The patient has apparently sought authorization from her Health Plan for a panniculectomy and lipectomy of the axillary tails resulting from her previous mammaplasty. The Health Plan had denied authorization for both procedures on the basis they are cosmetic in nature.In reviewing the provided materials, which include office notes from the patients primary care physician and her plastic surgeon as well as photocopied photographs of the patient, it is noted that the patients weight has been constant at 180 pounds since January 2004. The submitted photographic evidence clearly demonstrates a pannus well below the pubic syphilis. Given a pannus of such size, functional impairments are likely including severe unrelenting intertrigo. Thus, the patient meets medical necessity criteria for authorization of a panniculectomy. However, based upon the evidence provided there is no medical justification for removal of the residual axillary tails secondary to the patients mammaplasty. As such, the requested axillary lipectomy is cosmetic in nature and not medically warranted.Based upon the information set forth above, I have determined that although the requested panniculectomy is medically necessary for treatment of the patients medical condition, the requested axillary lipectomy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male with cardiomyopathy. He has an ejection fraction (EF) of 35% and is stable on his current medications, which include Avalide, a combination medication containing irbesartan and HCTZ. The patients provider recommends the patient continue taking Avalide, and has submitted a request for authorization to the Health Plan. The medication was not considered medically necessary, and the request was denied.There is no current data to suggest any clinical advantage for prescribing Avalide as compared to other angiotensin receptor blocking agents.  A trial of a similar formulary medication in the same drug class as Avalide is medically reasonable. Should the alternative medication not have medical effectiveness similar to Avalide, reconsideration of the patients request would be warranted.  Based upon the clinical record provided for review, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested for intensive outpatient program (IOP) services for treatment of her eating disorder.    Findings:  The physician reviewer found that the records clearly and consistently show that the patient continues to struggle with her eating disorder as demonstrated by binging and purging, her alcohol abuse and her feelings of helplessness, worthlessness and depressed mood. The patients symptoms and their intensity and frequency meet criteria for on-going treatment in the eating disorder IOP. Her symptoms have not stabilized to a point that she can transition to a lower level of care. The patients comorbid conditions of substance abuse and depression are also unresolved and have a significant impact on her eating disorder.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test. Findings:  Three physician reviewers found that FoundationOne gene testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hope of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis in this clinical setting. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (NCI-MATCH: Targeted Therapy Directed by Genetic Testing in Treating Patients With Advanced Refractory Solid Tumors or Lymphomas). However, genetic testing in this setting is still the subject of an ongoing phase II trial. As such, the genetic testing performed would be considered investigational/experimental for this patient. Therefore, FoundationOne gene test performed was not likely to be more beneficial than other standard options available for the evaluation of this patients medical condition. Final Result: 2 of 3 reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. 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 patient is a 15-year-old male with an apparent diagnosis of attention deficit hyperactivity disorder (ADHD). He had been treated with Strattera, recently at 40mg per day, with improvement noted by his parents. The Health Plan formulary approves methylphenidate and amphetamine as first-line therapy. However, the patients parent prefers Strattera due to side effects of formulary-approved medications. At issue is whether Strattera is medically necessary for treatment of the patients condition.Based on the records provided, Strattera is not medically necessary as a first-line therapy for this patient. Trials of formulary drugs should be tried. If the formulary alternatives are found unacceptable for medical reasons, thenother medications such as Strattera should be considered. Absent a trial of the formulary alternatives, use of Strattera is not medically warranted. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested 14 treatments of Avastin in combination with chemotherapy (carboplatin and Gemzar) for treatment of her metastatic ovarian cancer.  Findings:  Two physician reviewers found that the treatment of relapsed ovarian cancer can be quite complicated.  There are many agents that have good response rates.  One of the first determinations to make in relapsed patients is whether the tumor is platinum sensitive or resistant. Additionally, the longer the treatment-free interval, the higher the probability of response to platinum chemotherapy.  This patient went approximately 18 months without therapy and would be estimated to respond well to platinum.  The paclitaxel/platinum combination has proven to be better than single agent platinum therapy in several clinical trials and is now considered the standard.   Phase II studies with Avastin have shown promise in patients with platinum-refractory disease, which is not the case here.  In the setting of this first relapse, there is a lack of medical evidence indicating that the addition of Avastin would confer improved survival.  All told, 14 treatments of Avastin in combination with chemotherapy (carboplatin and Gemzar) were not likely to have been superior over other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for plastic surgery consult for breast reconstruction for treatment of the her breast ptosis following weight loss. Findings:  The physician reviewer found that the records do not include any office notes that document longstanding problems with sleeping, sexual dysfunction or emotional distress that have failed to respond to conservative treatments.In general, mastopexy is not a functional or reconstructive operation; it is a cosmetic operation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the L5-S1 anterior lumbar discectomy, anterior interbody fusion with PEEK cage Medtronic demineralized bone matrix, allograft bone chips L5-S1, posterior left L3-4 laminotomy for sub-lamina approach right L3-4 foraminal discectomy, L2-3 lumbar drain insertion, with stereotactic navigation performed on and three (3) day inpatient hospital stay provided . Findings:  The physician reviewer found that ss noted by a study, lumbar fusion is a commonly performed procedure for the treatment of painful instability of the spine, usually manifest as chronic low back pain. This patients records document a history of low back pain with L5-S1 disc degeneration. However, there is no documentation of any evidence of instability, fracture, or tumor. The current established criteria for lumbar fusion surgery have not been met based on the records provided for review. Accordingly, the L5-S1 anterior lumbar discectomy, anterior interbody fusion with PEEK cage Medtronic demineralized bone matrix, allograft bone chips L5-S1, posterior left L3-4 laminotomy for sub-lamina approach right L3-4 foraminal discectomy, L2-3 lumbar drain insertion, with stereotactic navigation performed and three (3) day inpatient hospital stay provided were not medically necessary for treatment of this 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 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 reimbursement for 30 treatments (two hours per treatment) of hyperbaric oxygen therapy (HBOT) in a multi chamber. The records provided for review document that this patient underwent a body contouring procedure with grafting of 2500 cc of fat to the flanks and buttocks. Postoperative evaluations performed after the procedure showed normal postoperative healing with swelling, tenderness, and ecchymosis. There was no report of findings indicating compromised healing of the liposuction or the fat grafted areas. There is no evidence of threatened or compromised surgical grafts. The patient underwent treatment with HBOT. However, there is a paucity of evidence in the medical literature to support the clinical utility of HBOT in free fat grafting by increasing the partial pressure of oxygen in the recipient tissue. Researchers noted that HBOT is ineffective when it is provided to patients who could heal without it. Medical literature shows that, HBOT is used on occasion to treat compromised flaps and grafts, where there is decreased perfusion or hypoxia, a practice supported also by the Guidelines from UHMS [Undersea and Hyperbaric Medical Society]. In addition, the authors noted that, HBOT can help maximize the viability of the compromised tissue hereby reducing the need for re-grafting or repeat flap procedures. Overall, there is a lack of peer-reviewed clinical literature documenting the benefit of HBOT in injectable fat grafting. This patient has no evidence of threatened or compromised surgical grafts, and the use of HBOT in injectable fat grafting is not supported by the medical literature. HBOT treatment to treat postoperative threatened or compromised surgical grafts status post body contouring procedure was not medically necessary in this patient. Thus, the 30 treatments (two hours per treatment) of HBOT in a multi chamber were not medically necessary for this patient. 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 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 virus.   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 treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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