Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of surface replacement arthroplasty of the left hip. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees osteoarthritis.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy 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 parent of an enrollee has requested Copaxone 40 mg for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Copaxone daily has resulted in pain and injection site lumps that make rotation of sites difficult.  Her provider has recommended Copaxone 40 mg, three times weekly.  Patient adherence can be impacted by side effects, such as pain and injection site reactions.  Overall, three times weekly injections are likely to be less irritating and foster adherence.  Copaxone 40 mg, three times weekly has been shown to have comparable tolerability and effectiveness as 20 mg daily.  Given the potential for optimized adherence, Copaxone 40 mg is medically indicated 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 authorization and coverage for physical therapy performed by a physical therapist capable of treating several complicated orthopedic issues in every session without the use of assistants twice a week.  The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not include physical therapy prescriptions documenting the recommended exercises, therapy modalities and goals. Per the records, the patient underwent physical therapy from January 2018 through March 2018, which has primarily consisted of manual therapy and ultrasound. There have been various complaints and minor injuries during this period. The duration that she has been undergoing this therapy before January 2018 is not documented or discussed.There is a lack of proven health or functional benefit of manual therapy such as myofascial release and ultrasound provided on a long-term basis. There is no proven marginal benefit with respect to palliation of these interventions over self-applied topical thermal modalities and independently performed soft tissue work, such as using a foam roller. There are no documented exercises that the patient has been performing in the formal therapy setting that could not be performed independently or substituted with independent exercise. The focus of treatment in the setting of chronic musculoskeletal spine and other body region pains should be patient education, self-care, common analgesics, independent exercise and remaining active. The benefit of prolonged formal therapy services is not established in the medical literature for these types of conditions.With respect to frozen shoulder, the clinical consensus regarding treatment of adhesive capsulitis of the shoulder has been to address etiological factors, if identifiable, and to start a gentle range of motion program that progresses over time.  The range of motion program can be started in a formal setting by physical therapists, but should be transitioned to an independent program over time.  Importantly, frequent range of motion exercise in the home setting has been shown to play a larger role in effectuating positive outcomes than the frequency of joint mobilization in a formal therapy setting. Therefore, the requested physical therapy performed by a physical therapist capable of treating several complicated orthopedic issues in every session without the use of assistants twice a week is not medically necessary 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 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: Medical Necessity
Decision: Upheld

A 54-year-old male, with a history of Parkinsons disease, has requested authorization and coverage for a power-operated vehicle (POV).Reviewers Findings:The reviewing physician found that the patients mobility-related deficits (decreased balance and retropulsion) can be corrected by using a walker and/or a manual wheelchair. Mobility-related activities of daily living can also be completed with a walker/manual wheelchair without increased risk of morbidity from a fall.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing for evaluation of the enrollees non-small cell lung cancer (NSCLC). Findings:  Two of the physician reviewer found that genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients and thus to facilitate prompt treatment or protocol inclusion. The National Comprehensive Cancer Network (NCCN) guidelines indicate that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. The NCCN non-small cell lung cancer (NSCLC) guidelines panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. For the treatment of patients with advanced NSCLC broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. As such, the Guardant360 gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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

A fifty year-old female who has had a history of chronic pelvic pain is seeking reimbursement for the previous physical therapy as well as authorization for additional therapy. Reviewers Findings:  The reviewing physician found that there is adequate scientific evidence demonstrating the benefit of utilizing physical therapy to treat certain types of chronic pelvic pain.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical breast augmentation for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. Based on the patients diagnosis and history, her external anatomy should be more consistent with a female than a male.  Her examination detail and review of the photographs support that she has had insufficient breast development and thus continues to be more consistent with a male chest contour than a female one.  The patient is well documented to have gender dysphoria. Thus, her external anatomy should be more consistent with a female than a male. As stated above, despite her hormonal therapy, she continues to have evidence of a male chest contour with minimal breast development. Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate. Therefore, surgical breast augmentation is medically necessary for the treatment of this patients gender dysphoria. Additionally, the requested surgical breast augmentation should be considered reconstructive in nature. The submitted clinical documentation and photographs support that she has abnormal breast development for a female. The patients abnormal condition is a result of her diagnosis of gender dysphoria. Her breast growth has not been sufficient despite hormonal therapy. The requested surgical breast augmentation would be to create a more normal appearance of breasts for a female and would be able to provide more than a minimal improvement in the appearance of female breasts. Thus, the requested surgical breast augmentation is reconstructive in nature and not cosmetic for treatment of the patients gender dysphoria.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. 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: Upheld

A 64-year-old female enrollee requested authorization and coverage of a referral to a surgeon for consultation and treatment. The Health Plan denied the request indicating that the requested referral is not medically necessary for the treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested authorization and coverage for individual psychotherapy with long-term multi-modal approach including unconditional positive regard/mirroring.  Findings:  The physician reviewer found that based on review of the available records, the patient is pursuing treatment from an independent provider who has recommended continuation of individual therapy. The provider states that psychotherapy with long-term multi-modal approach including unconditional positive regard/mirroring is indicated for this patient. However, there is inadequate documentation supporting this specific approach. The independent provider will be offering medically similar treatment to the services available within the patients Health Plan. The records suggest that the apparent tension and poor rapport between the patient and his therapists has likely hindered progress. The patient indicated that he has seen many therapists who have used many modalities over the years which were ineffective. The patient does require individual psychotherapy on an ongoing basis. However, the requested individual psychotherapy with long-term multi-modal approach including unconditional positive regard/mirroring approach is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for laparoscopic esophageal sphincter augmentation with placement of sphincter augmentation device. The enrollee has a history of gastroesophageal reflux disease. The enrollee reports a primary symptom of chronic cough for six years. He underwent testing, which showed class B esophagitis. Other test results were consistent with chronic gastritis. During a surgery consultation the general surgeon recommended treatment with the LINX Reflux Management System. The LINX Reflux Management System may provide a way to treat gastroesophageal reflux disease for people who have not improved with medication. Studies show this procedure can improve symptoms and help people lower their medication use. This enrollee meets the criteria for the requested procedure.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology 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 38-year-old female enrollee requested authorization and coverage of a videostroboscopy for the treatment of chronic laryngitis.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 55-year-old woman with Lyme disease and chronic foot pain. The patient has undergone surgery, though her pain persists. She has tried multiple medications to relieve her pain. The patient requests authorization for Celebrex. The Health Plan has denied the patients request indicating that Celebrex is not medically necessary for treatment of the patients foot pain.The patients medical condition requires the use of Celebrex, as it is the only medication that helps relieve her pain. Based upon the submitted documentation, the patient has tried Bextra, Relafen, and Vioxx, but found that these medications were ineffective or caused intolerable side effects. Celebrex has been effective for this patient without causing significant side effects. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Panniculectomy involves the removal of the lower abdominal skin without the muscle tightening or supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty.  Per the submitted photographs, this patients pannus skin fold has resulted in a disruption of skin integrity.  The medical records note that the patient has a skin condition which has been resistant to medications, and the pannus hangs below the pubis.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested panniculectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested for Synvisc for treatment of her osteoarthritic changes in her knees. Findings:  The physician reviewer found that Viscosupplementation has a documented moderate positive effect on patients with osteoarthritis of the knee. Although the documentation is limited, it appears as if the patient improved with the first course of Synvisc, as the provider noted excellent prolonged improvement. Synvisc is medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested inpatient psychiatric treatment services for treatment of the enrollees behavioral health issues status post suicide attempt. Findings:  The physician reviewer found that in being consistent with the Child and Adolescent Level Of Care Utilization System (CALOCUS) and American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters, this patient met the criteria for treatment in a controlled 24-hour setting from the dates of service at issue. To ensure her safety, she required the intensive treatment in a multidisciplinary setting for the period at issue. Applying CALOCUS criteria, this patients risk of harm would be rated severe as she engaged in serious attempts at suicide in the past and acknowledged she would continue to do so outside of a controlled environment. She displayed serious functional impairment with sleep disturbance, anxiety and disrupted relationships with others. There were substantial co-morbid issues including major depression, post-traumatic stress disorder (PTSD) and substance abuse adversely impacting her recovery. The presence of an extremely stressful recovery and home environment such as the suicide of a family member and friend, and anger at her parents were additional factors supporting care in a 24-hour setting. In addition to prior hospitalizations for suicide attempts, the patient was treated on an intensive outpatient basis prior to the admission at issue. The records indicate that all of these previous attempts at therapy failed to provide adequate control of her symptoms prior to her transfer to the 24-hour treatment facility. In summary, the residential inpatient services received during the time period at issue were medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested residential treatment services for treatment of the enrollees generalized anxiety disorder, mood disorder, not otherwise specified, cannabis dependence, and sedative, hypnotic or anxiolytic abuse.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Although determining the optimal length of stay and ideal treatment setting represents a challenge to treating providers, the documentation provided does not support the medical necessity of treatment at the residential level. The submitted records do not demonstrate that treatment was improving the patients condition and preventing a more serious health condition.  Aside from the reported failure of outpatient services, there was no elaboration of past treatments or clinical explanation opined by the treatment team articulating the value of the residential setting as opposed to comprehensive interventions in a less restrictive setting.  In the absence of such clinical documentation, the medical necessity of the services at issue cannot be established.  Thus, residential treatment services is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old male enrollee has requested intensive outpatient program mental health treatment for his polysubstance abuse.   Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity for the services at issue. This patient has not consolidated the treatment gains necessary to succeed in a less restrictive setting. Throughout his treatment he was frequently withdrawn, even blunted. To decrease services in such a scenario is inconsistent with accepted medical practice. In the absence of intensive outpatient programming, the patient will likely relapse and endure undue morbidity and may require treatment at a higher level of care and/or face a poor clinical outcome. This patient requires a period of sustained sobriety along with improved insight, optimization of his psychosocial support system and enhanced coping strategies to impart meaningful change and foster independent, successful and drug-free living. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were and are medically necessary for treatment of the patients medical condition