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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment regimen of Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the medical guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed regimen of Harvoni is consistent with FDA guidelines and is medically necessary to prevent further development and progression of fibrosis due to ongoing HCV infection. All told, the requested Harvoni is medically necessary for treatment of the patients hepatitis C virus. 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

The patient is a 51-year-old male who injured his knee while out of state. He was evaluated in the emergency room and an evaluation by an orthopedist was recommended. A few days later the enrollee was evaluated by an orthopedist and an MRI was recommended. The patient remains out of state and the Health Plan has denied authorization for the MRI on the basis that it is not considered an emergent or urgent service. The Health Plans denial should be upheld. Although an MRI appears indicated for this patient it is neither emergent nor urgent in nature. The documentation submitted demonstrates the evaluating orthopedist did not consider the MRI emergent or urgent in nature. The Health Plan indicates it will provide an MRI to the patient when he returns to his state of residence. There is no indication in the information provided that the requested MRI needs to be provided on an emergent or urgent basis. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old woman with longstanding problems with her right knee. The patient has undergone two prior surgeries. She is status post anterior cruciate ligament (ACL) reconstruction and now requires a revision of this surgery. A request has been made for a continuous passive motion (CPM) unit postoperatively. The Health Plan has determined that a CPM unit is not medically necessary for the patients postoperative rehabilitation.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. In the case of this patient, she clearly experienced a benefit from use of a CPM unit following her prior surgery. In addition, the patient has a history of motion and stiffness problems that developed after her first knee surgery. Furthermore, there are no significant risks posed by use of a CPM unit. Given the patients history, her prior problems, and her success with use of a CPM unit in the past, a CPM unit is medically reasonable and indicated for the patients successful postoperative rehabilitation. Based upon the evidence set forth above, I have determined that the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested orthodontic services for treatment of the enrollees medical condition. Findings: The physician reviewer found that the review of the submitted clinical documentation fails to demonstrate the medically necessary for the services at issue. In the setting of mixed dentition, there is a lack of support in the dental literature demonstrating benefit to interceptive treatment where the patient is still expected to have significant growth which will somewhat mitigate the dental crowding observed as described in this case. In addition, the patients score on the Handicapping Labio-lingual Deviation (HLD) index was well below the accepted minimum score required to indicate a severe handicapping malocclusion. Given the clinical documentation demonstrating minimal crowding of the teeth, the orthodontic services at issue were not indicated 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 physician reviewer is board certified in dentistry 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 is a 55-year-old female with a partial bilateral mastectomy and failed non-autologous breast reconstruction. She is seeking authorization for a superior gluteal artery perforator (S-GAP) bilateral breast reconstruction. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary. The Health Plan has recommended other reconstructive procedures for the patient.Elective, optimal breast reconstruction surgery is medically necessary for treatment of patients post mastectomy. However, based upon the information provided, it has not been objectively established that breast reconstruction using the S-GAP procedure is medically necessary for this patient. While the S-GAP procedure may be more appropriate than other reconstructive procedures in light of the patients weight of approximately 135 pounds, the clinical information provided is not sufficient to determine whether the requested procedure is medically warranted. Therefore, the patient should be re-evaluated by an in-network microvascular reconstructive surgeon; if the surgeon determines an S-GAP reconstructive procedure is medically necessary, the procedure should be authorized.Accordingly, I have determined the requested procedure is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee requested a power wheelchair and batteries for treatment of her medical condition. Findings:  The physician reviewer found that the medical records do not establish that the patient would be confined to a bed or chair without a power mobility device.  The records indicate that the patients strength and sensation have been intact, and her gait has been normal per her providers examination.  A power mobility device is not medically necessary for this patient given that the records do not establish objective mobility deficits.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested emergency room services provided on an emergent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with upper respiratory symptoms with a fever. The patient denied any shortness of breath or vomiting. She was noted to be in no acute distress. Her temperature was elevated, which resolved with administration of oral acetaminophen. No radiologic studies or laboratory testing were performed. While parental concerns were noted over the patients persistent fever, the patients symptoms were not sudden or acute in onset. Moreover, the patient was not in acute distress and there was nothing in the patients history, physical exam, or ER evaluation that indicated any emergent or even urgent medical condition. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe the patient was suffering from a serious medical condition that required immediate medical attention. In sum, the patient was not experiencing a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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

The parent of a 16-year-old male enrollee has requested  coverage for free vascularized fibular grafting surgery for treatment of the enrollees osteonecrosis of the right femoral head. Findings:  The physician reviewer found that the treatment of early avascular necrosis (osteonecrosis) of the femoral head remains controversial, with core decompression being the standard treatment for this disorder. The  development of osteoarthritis over time is to be expected, likely requiring additional reconstructive surgery. Additionally, the utilization of a free vascularized fibular graft would not appear to offer any particular benefit to the patient, such as greater joint preservation or reduction in pain, over the surgical procedures typically performed in this setting. All told, there is a lack of scientific evidence demonstrating that free vascularized fibular grafting surgery is likely to result in a superior clinical outcome compared to standard surgical intervention in this setting.
Appeal type: Urgent Care
Decision: Overturned

A 30-year-old female enrollee has requested  emergency services for treatment of her abdominal pain and gross hematuria.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates this patient had a history of UTIs and had experienced the rapid onset of symptoms of a UTI on the disputed date of service. Untreated, this uncomplicated infection could have ascended the urinary tract to involve the kidney and thus could have become a serious, life-threatening infection. Waiting until the next day to seek diagnosis and treatment for this obvious infection would not have been prudent. In addition, the patients pain level was 7/10 (a level compatible with severe pain). In sum, a prudent layperson would have thought the patients symptoms represented an emergency medical condition and would have sought immediate medical attention on the date in question.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female has requested surgery (thigh excision).   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  The reviewed records do not justify the medical necessity of the removal of these masses.  If the masses were of sufficient size to rub against the opposite leg, they would protrude beyond the normal skin surface contour and would likely be visible in the photographs.  No such mass protrusion is visible in the photographs contained in the reviewed records.  The documentation does not support a functional deficit due to left thigh masses.  All told, the requested surgery (thigh excision) is not medically indicated for the treatment of this patient
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the pelvis and of the abdomen for evaluation of the enrollees asymptomatic microscopic hematuria.  Findings:  The physician reviewer found that This patient has a longstanding history of microhematuria and a work-up in the past which has reportedly been negative. Recently, the increase of red blood cells in the urine was noted to be an indication for additional imaging of the urinary tract. However, the exam of choice is a CT of the abdomen and pelvis to evaluate the kidneys and bladder as well as the entire genitourinary tract including the collecting systems, ureters and bladder. The American College of Radiology (ACR) appropriateness criteria supports the use of CT as the best procedure of choice in this clinical setting. Although the patient declined a CT due to concerns regarding radiation exposure, the MRI would not have been an effective alternative without the intravenous contrast. Intravenous contrast was needed to thoroughly evaluate the patient for an uroepithelial tumor, which requires opacification of the collecting systems and bladder. All told, the MRI of the pelvis and the MRI of the abdomen were not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 prescription medication Zioptan 0.0015%, one droplet in each eye, once a day. Findings:  The physician reviewer found that in a comparison of bimatoprost, latanoprost, travoprost, and tafluprost that all four drugs equally and significantly reduced the intraocular pressure in patients with primary open-angle glaucoma. In this case, the patient has tried and failed Alphagan, latanoprost, and preservative-free dorzolamide-timolol combination drops. Given that there is a lack of reasonable alternatives for treating the patients glaucoma, Zioptan is medically indicated. Therefore, the prescription medication Zioptan 0.0015%, one droplet in each eye, once a day is 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 ophthalmology 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 enrollee who presents with a four-year history of growth over his left eye cornea, getting progressively worse. He was evaluated for an initial consultation. A nasal pterygium was found on examination, and best corrected visual acuity (BCVA) of 20/25 was measured in the left eye. A repeat visit revealed a left pterygium and BCVA of 20/25 in the left eye. Corneal topography showed irregular astigmatism associated with nasal pterygium of 2D cylinder in the left eye.  The astigmatism extended into the central four mm of central corneal surface. The patient was evaluated by a primary care physician who found a left eye pterygium extending onto the cornea and referred the patient to another specialist. The provider noted the patients BCVA was 20/30. However, his measurements of the pterygium at the slit lamp were only in the range. The second specialist declined surgical removal of the pterygium. No corneal topography was reportedly obtained by the second specialist to evaluate corneal astigmatism that maybe induced by astigmatism.   As noted in the medical literature, corneal topography is a reliable measurement of a lesion since it can be repeated and should be consistent from provider to provider. The first specialist who evaluated the patients corneal topography documented irregular astigmatism in the left eye, which corresponded to the pterygium location. This corneal topography finding is a more reliable assessment of the true size of a pterygium and its effect on the patients vision. A pterygium can cause irregular astigmatism and reduce the quality of vision even before it encroaches on the pupil. Considering this patients age, the risk of the recurrence is low, especially with the use of intra-operative mitomycin and post-operative prednisone drops. Removing the pterygium is indicated for this patient, as it is inducing irregular astigmatism that extends onto the central of cornea. Given these findings, the requested removal of pterygium is medically necessary for treatment of this patients medical condition. 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 ophthalmology, 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 57-year-old female enrollee, with a long-term history of migraine headaches, has requested authorization for the prescription medication Zomig. Findings:  The physician reviewer found that Maxalt is likely to be as effective in treating this patients migraines without untoward side effects, as Zomig has been. It is not clinically unreasonable for the Health Plan to request a trial and failure of Maxalt prior to authorization of Zomig.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual acupuncture for treatment of headaches, musculoskeletal pain and nausea. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The records note a recent flare-up of her chronic neck, shoulder and lower back condition related to a fall. Due to the severity of the pain, medication was required which produced nausea and lightheadedness. Researchers described the effectiveness of complementary and alternative medicine therapies compared to placebo, no intervention, or other interventions for acute/subacute and chronic low back pain. The authors noted that acupuncture is more effective than no treatment for chronic low back pain. Other researchers performed a recent randomized controlled trial comparing usual care to acupuncture plus usual care. The authors found that at 24 months the acupuncture/usual care subjects were significantly more likely to report 12 months pain free and less likely to report they required use of medication for pain. As this patient described functional improvement and symptom reduction with prior six acupuncture sessions, the requested individual acupuncture is medically necessary for the 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 oriental 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 40-year-old female enrollee has requested nasal debridement surgery, endoscopy of the maxillary sinus and/or removal of the ethmoid sinus for treatment of her nasal polyps. Findings:  The physician reviewer found that based on the information provided, this patient apparently underwent some sort of surgery for the treatment of nasal polyps, However, the details regarding this procedure are not clearly documented in the records provided. Postoperatively, she received Kenalog injections twice. The submitted records do not clearly document the patients history or previous treatment. The only radiologic report submitted was a chest x-ray. All told, there is a lack of clinical findings demonstrating that this patient meets clinical indications for nasal surgery. Thus, based upon the submitted documentation, the medical necessity of the requested procedures has not been established. The requested nasal debridement surgery, endoscopy of the maxillary sinus and/or removal of the ethmoid sinus is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old male enrollee has requested a wearable cardiac defibrillator (LifeVest) for treatment of his non-ischemic cardiomyopathy.   Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to Chung and colleagues, for patients felt to be at high risk of SCD while undergoing a trial of optimal medical therapy, the WCD provides protection against SCD while awaiting improvement in LV function. One of the Centers for Medicare and Medicaid Services (CMS) approved indications for a wearable defibrillator vest is the presence of a dilated cardiomyopathy and a measured left ventricular ejection fraction of less than or equal to 35%. Therefore, patients such as in this case, who are at significant risk from SCD would benefit from risk reduction with a wearable cardioverter defibrillator until such time that it can be determined whether he has sufficient recovery in cardiac function, or whether he needs a permanent implantable cardioverter defibrillator ( ICD). All told, the services at issue were likely to be more beneficial for treatment of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee requested authorization and coverage of a PET scan. The Health Plan denied the request indicating that the requested PET scan is not medically necessary for evaluation 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 PET scan is medically necessary.