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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for hysterectomy.Hysterectomy is considered the definitive management for abnormal uterine bleeding and may also help with the treatment of pelvic pain. According to medical literature, a hysterectomy is performed to control bleeding. In this case, the patient has been worked up, with imaging showing evidence of uterine adenomyosis. First-line treatment options have been attempted, including medical management with hormone therapy. Although she has tolerated the Mirena IUD, her abnormal bleeding symptoms have persisted, and she continues to experience pelvic discomfort. Furthermore, she has a family history of ovarian cancer. For definitive management of her symptoms, hysterectomy is the appropriate next step. Thus, the requested hysterectomy is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested prescription medication Invega for the treatment of attention-deficit hyperactive disorder (ADHD).  Findings:  The physician reviewer found that the FDA approved indications for this medication do not include the treatment of ADHD in children or adults. There are no studies available to support the use of Invega in the treatment of pediatric ADHD. Invega is not known to be an effective in this setting and its use is not consistent with the community standard of care for the treatment of ADHD.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested for bilateral reduction mammoplasty for treatment of her symptomatic macromastia. Findings:  The physician reviewer found that there is a lack of documentation of diagnosis and failure of conservative treatment for skin rashes, intertrigo or skin ulcerations secondary to macromastia. In terms of the reconstructive surgery considerations, the necessary criteria for that are not met. The patients breast size does not constitute an abnormal structure of the body. There is no abnormal structure or abnormally functioning member due to congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Therefore, the surgery cannot be considered as reconstructive surgery.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 51-year-old female who initially complained of stress urinary incontinence (SUI) with coughing in November 2004.  At that time she was instructed to perform kegel exercises. The patient returned to her provider in March 2006 reporting no improvement in her SUI.  She was prescribed an electrical pelvic floor stimulator. The patient purchased the device and is now requesting reimbursement.  The Health Plan denied her request citing a lack of medical necessity.There is no question that behavioral therapies such as bladder training, pelvic muscle rehabilitation and biofeedback have a place in the treatment of SUI. In fact, these modalities are usually recommended as first-line conservative management prior to consideration of surgical treatment. It is true evaluation of the success of these various approaches to the treatment of incontinence is difficult as there is often overlap in the types of incontinence (stress, urge and mixed). At the present time there are differences in how behavioral therapies are conducted and there is little agreement in the medical community as to a quantifiable endpoint. Patient satisfaction or the patients perception of improvement is often the best measure of success. Nonetheless, behavioral modifications have been reported as resulting in 50% to 70% improvement or reduction in incontinence episodes. The electrical pelvic floor stimulator has been found to produce a similar rate of improvement when compared to other behavioral therapies. In this case, kegel exercises did not effectively relieve the patients symptoms and the electrical pelvic floor stimulator was a reasonable next step in the conservative management of her SUI.  Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested a thoracic facet joint injection for treatment of his pain. Findings:  The physician reviewer found that thoracic facet injections are not likely to be diagnostic or therapeutic for this patients medical condition. In addition, there is little evidence and support in the medical literature for thoracic facet injections in the diagnosis and treatment of thoracic pain.  Boswell and colleagues performed a systematic review to provide an updated evaluation of the effectiveness of three types of facet joint interventions in managing chronic spinal pain. The review measured pain as the primary outcome.  It was determined that for cervical, thoracic and lumbar medial branch nerve blocks with local anesthetics, with or without steroids, evidence is moderate for short-term and long-term pain relief with repeat interventions. The evidence for pain relief with thoracic radiofrequency neurotomy is indeterminate.  Bogduk summarized and analyzed the available literature on the efficacy of intra-articular injections of corticosteroids for low back pain.  He found that the only rationale for intra-articular steroids appears to be expectation that they should work. He further wrote that when the results of observational studies are pooled, they paint a picture of impressive immediate responses, but a rapid decay of outcomes by three and six months. The current medical evidence does not support the requested service in this patients case. All told, the requested thoracic facet joint injection is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested for the prescription medication Aciphex (20 mg twice daily) for treatment of his acid reflux. Findings:  The physician reviewer found that the patient should attempt appropriate trials of Prevacid, Protonix or Omeprazole prior to consideration of Aciphex.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tysabri infusions. Multiple sclerosis is a progressive condition which leads to worsening neurological disability. Researcher describes natalizumab as the first humanized monoclonal antibody indicated in the treatment of relapsing-remitting multiple sclerosis (RRMS). The researcher noted natalizumab was indicated in active RRMS based on its remarkable efficacy in reducing disease activity and reducing the risk of disability progression. Medical literature noted that the choice of using natalizumab was currently based on the professional experience of the neurologist, and on patients clinical features and preferences. In this case, the patient has multiple sclerosis and has recurrent symptoms. Given the current medical literature and the providers recommendation that the patient continue on Tysabri, the requested treatment is medically indicated. Therefore, Tysabri infusions are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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 reimbursement and prospective authorization and coverage for skilled nursing facility services for treatment of the enrollee, who has a history of polyneuropathy with weakness. Findings:  The physician reviewer found that the records document a history of alcohol use disorder, polyneuropathy with weakness, hypertension and obstructive sleep apnea. The patient presented to the emergency department with increasing weakness as well as urinary and fecal incontinence. At the time of discharge from the hospital, the patient did not require any skilled nursing or rehabilitation services on a daily basis. The patient was not at his prior level of functioning. However, he did not require admission to a skilled nursing facility for inpatient skilled rehabilitation services. The patient was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The patient did not require skilled therapy to establish a safe and effective maintenance program. The patient did not require any skilled services on an inpatient basis, at a skilled nursing facility level of care.  He did not have any parenteral medications, complex wound care or nutrition given via a feeding tube. The patient was medically stable and could have received further services at a lower level of care. His physical function was near his baseline, and he could have received services at a lower level of care.  Final Result: The reviewer determined that the services at issue were not 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 internal 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

An eighteen year-old male with diagnoses of attention deficit disorder (ADD), depression, and temporal lobe dysfunction have requested authorization of Provigil.Reviewers Findings:  The reviewing physician found that although the current literature does suggest some degree of efficacy for Provigil in the treatment of ADD, it is not yet an FDA approved indication.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested home health care.  for treatment of his paraplegia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Patients with spinal cord injury are at high risk for pressure ulcers.  In addition, once formed, pressure ulcers can be difficult to heal due to metabolic and physiological changes in the tissues below the level of the spinal cord injury.  With respect to treatment, the key areas of focus remain ongoing appropriate pressure relief, optimizing nutrition, modifying behavioral factors such as smoking, and promoting an optimal wound environment.  In this case, the patient has multiple chronic wounds that have reportedly persisted for years despite extensive home health services.  He does not have any documented impairments that would be expected to preclude his ability to complete his wound care independently with an appropriate set up and training.  Home nursing notes document that he is able to perform his wound care.  The patient is not homebound and can follow-up in a wound care center for intermittent debridements, as needed.  All told, the requested home health care is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested  for continued mental health inpatient hospitalization for treatment of the enrollees major depressive disorder, recurrent, severe, with psychotic features, cognitive disorder, not otherwise specified and rule out schizoaffective disorder. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System and the American Academy of Child and Adolescent Psychiatry Practice Guidelines support this level of care for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 50-year-old male enrollee requested authorization and coverage of residential treatment services for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested Xyzal 5mg daily for the treatment of her respiratory allergies. Findings:  The physician reviewer found that clinical comparison studies have demonstrated that Xyzal is a more effective second-generation antihistamine than Zyrtec, Claritin, Clarinex and Allegra due to a lower volume distribution and higher receptor site binding capacity (i.e., it provides more protection and has a longer duration). Therefore, the use of Xyzal in this situation is appropriate and generally accepted as the standard of medical care, as the patient has failed other first and second-generation antihistamines.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested automated external defibrillator (AED) for treatment of the enrollees long QT syndrome. Findings: Two physician reviewers found that the request for an AED has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient does not fulfill the requirements for an implantable cardioverter defibrillator (ICD) as he has not been treated with beta blockers and is currently asymptomatic with no syncope or documented arrhythmias. Although, the patient does not meet the criteria for an ICD, he remains at high risk of having arrhythmia. An AED is necessary in the event that the patient does have a life threatening arrhythmia. AEDs have been proven to save lives. Survival is greatest when the AED is placed within three to five minutes of a witnessed collapse. In this case, the patient has a QTc greater than 500 milliseconds which puts him in a high risk category for a malignant arrhythmia. Accordingly, a personal AED is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested device is 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:  All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 57-year-old male enrollee requested authorization and coverage of proton beam therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested outpatient psychotherapy office visits at a frequency no less than every other week for treatment of her dysthymia. Findings:  The physician reviewer found that in the case of this patient, the physician letter from said date indicates the patient was making progress with her boundary management and assertiveness.  Even though not quantifiable, this is indicative of clinical progress and the consolidation of treatment gains. Considering the duration and frequency of treatment up to that point, coupled with multiple psychosocial stressors and history of suicidality, the psychiatrists request for six months of twice monthly therapy for a period of six months in said date was reasonable. However, there is no documentation of a comprehensive treatment plan, which is a crucial document that develops and organizes interventions aimed at maximizing the patients level of functioning as well as helping the patient to set specific goals appropriate to his or her functional impairments and symptom severity (Gelenberg, et al). Further, longitudinal clinical documentation has not been provided. Information such as the specific symptom complex, developmental history, treatment history, quantifiable goals, barriers to progress, multidisciplinary contributions, physical examination and supportive community interventions represent additional factors that would allow one to determine if the increased frequency and duration of sessions are bolstering autonomy and resiliency while mobilizing the patient towards remission and averting treatment at a higher level of care. Given the lack of a comprehensive treatment plan and evidence of specific functional impairment, grave disability or imminent threat, I have determined that although twice monthly outpatient therapy from time frame specified was medically necessary, the medical necessity of twice monthly outpatient therapy sessions from said date forward has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgery to set and straighten her leg 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.  This patient is a paraplegic with no lower extremity sensation or power.  She sustained a fracture.  She has no pain, and has returned to normal functional activity.  Surgical treatment of this fracture is not indicated based on pain or function.  Contraindications would include the lack of lower extremity function and osteopenia which would place the patient at high risk for delayed fracture healing and nonunion.  All told, the requested surgery to set and straighten the left leg 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 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

A 57-year-old male requested authorization and coverage of peginterferon alfa-2b (PegIntron) for the treatment of chronic Hepatitis C.  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 treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the patient has a strong history of breast cancer, and also has a personal history of melanoma. Considering all factors including her age, medical history, personal history of malignancy, and strong family history of breast cancer, tomosynthesis is a reasonable tool for this particular patient. All told, 3D breast tomosynthesis was 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

The enrollee is requesting authorization and coverage for facial feminization surgeries.  She understands the surgical risks and benefits. The enrollee has experienced gender dysphoria for 20 years. Although these surgeries do not require a referral by mental health professionals, these professionals play an important role in assisting people with making a fully informed decision about the timing and implications of these procedures. Most of these procedures are generally labeled purely aesthetic, but for an individual with severe gender dysphoria they can be considered medically necessary, depending on the unique clinical situation of the individual. The records indicate the enrollee has the capacity to make a fully informed decision, did not have a significant medical health concern and there were no mental health concerns present. The enrollee is undergoing therapy, as needed and will continue to do so.  The records support the patients readiness to undergo the surgical intervention as she had been living as a woman and is comfortable as a woman.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.