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

The enrollee is a 50-year-old transgender male who has requested for sexual reassignment surgery, specifically free-flap phalloplasty for treatment of the enrollees gender identity disorder. Findings:  The physician reviewer found that free-flap phallus reconstruction has been the preferred phallus reconstruction procedure in female-to-male transgender patients since the 1980s. It allows for a normal-sized male phallus that has the potential for voiding while standing and is capable of sexual penetration. The radial forearm and the anterior lateral thigh flap are the preferred techniques. The Health Plan contends free-flap phalloplasty is associated with serious complications including fistulas and strictures. However, fistulas and strictures would be considered minor complications. Further, sexual reassignment surgery is complex and complications are expected regardless of the type of phallus reconstruction procedure that is utilized. Moreover, phallus reconstruction using the metoidioplasty approach does not adequately address two of the primary reasons female-to-male transgender patients undergo phallus reconstruction  the ability to achieve sexual penetration and to void while standing. According to the article by Hage and colleagues, at best, metoidioplasty will provide a small phallus hardly, if at all, capable of sexual penetration. Given the advantages of free-flap phalloplasty as compared to metoidioplasty, the requested procedure is medically necessary for treatment of the patients gender identity disorder.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested psychotherapy once per week for treatment of her depression.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients afflicted with affective disorders, such as major depressive disorder. Current psychiatric practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. This concept is effectively captured by the American Psychiatric Association. Considering the recurrent nature of major depressive disorder, it is not uncommon that discrete episodes of illness, as in this case, will demand greater clinical attention to preserve functionality and avert treatment in a more restrictive setting, if not a more catastrophic outcome. Although a formal treatment plan with systematic monitoring to assess progress would be an appropriate approach, this patients provider has also identified reasonable treatment goals based on psychodynamic theoretic principles. All told, a limited course of evidence-based individual psychotherapy on a weekly basis is safe, appropriate, and consistent with good medical practice as it is supported by current practice guidelines. Accordingly, the requested weekly psychotherapy sessions are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for omalizumab (Xolair) 300 mg (60 units) subcutaneous injection every four weeks. Findings:  The physician reviewer found that Kaminsky and colleagues report that the treatment options for patients with idiopathic anaphylaxis who fail to respond to antihistamines and mast cell stabilizers are currently limited. The authors further note that treatment with omalizumab may be an effective option for these patients. In this case, the records note a diagnosis of idiopathic anaphylaxis and multiple episodes of anaphylaxis that cannot be anticipated. Given that conservative measures and treatments have not helped prevent attacks, the requested medication is medically indicated. Therefore, omalizumab (Xolair) 300 mg (60 units) subcutaneous injection every four weeks 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 internal medicine and in allergy and immunology 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 60-year-old female enrollee has requested hormone replacement therapy (HRT) for the treatment of her postmenopausal osteopenia. Findings:  The physician reviewer found that this patients medical issues are multifactoral and estrogen deficiency is only one of the factors. She has abnormal liver function, possible diabetes, depression, irritable bowel syndrome, and osteoporosis. The patients primary care provider has declined to prescribe HRT as the provider is reasonably concerned with the patients history of smoking and possible related risks for cardiovascular problems and deep vein thrombosis. The provider also addressed the possible risk of ovarian cancer with use of HRT. The records indicate the patient received HRT for more than five years in the past. In the medical literature, although it has been suggested that HRT may protect against some malignancies (i.e., colon cancer) it has been documented to increase the risk of other malignancies. Corbin and colleagues indicate that HRT is contraindicated in active liver disease. This patient has elevated liver enzymes attributed to fatty liver. Furthermore, while it is not clear from the records provided how long the patient has been off of estrogen, there is an increase in cardiovascular disease when initiating HRT later in menopause as noted by Rossouw and colleagues. All told, the risks of HRT outweigh the potential benefits for this patient. As the literature suggests, the use of HRT in this setting is not recommended.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sensipar. The records provided for review document the patient has a hyperplastic parathyroid gland that has not reduced in mass since his kidney transplant. The parathyroid gland is hyperactive and cannot be inhibited with non-calcium binders. Oral vitamin D is also contraindicated as it would worsen the patients hypercalcemia. Treatment options are limited to surgery or Sensipar to avoid the risk of nephrolithiasis. Thus, Sensipar is appropriate as the least invasive and most effective treatment option. Accordingly, the requested Sensipar is supported as medically necessary for treatment of this patients medical condition. 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 nephrology 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 Dexcom G4 Platinum Continuous Glucose Monitor, including transmitter, receiver and sensors for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested equipment in this patients case.  Malik and colleagues noted that for patients with hypoglycemia following bariatric surgery, continuous glucose monitoring is a valuable tool, revealing the episodes in the natural environment and can also be used to monitor treatment success.  The Dexcom G4 Platinum Continuous Glucose Monitor is of particular benefit for the prevention and detection of hypoglycemia.  In this patients case, the records suggest an emerging condition called post gastric bypass hypoglycemia.  The Dexcom G4 will be able to monitor her glucose levels continuously, and alarm her when a glucose fluctuation is occurring so that she may take action and prevent severe hypoglycemia. This offers an advantage over conventional fingersticks with which the time in between testing is blind and patient may not realize that she has hypoglycemia until the glucose is very low.  All told, the requested Dexcom G4 Platinum Continuous Glucose Monitor, including transmitter, receiver and sensors are medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and metabolism 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 50-year-old female enrollee has requested steroid-free protocol as part of her kidney transplant surgery for treatment of her chronic kidney disease. Findings:  The physician reviewer found that one of the major risks of renal transplant is the possibility of rejection of the transplanted kidney. Current therapeutic protocols for kidney transplant patients have markedly reduced the incidence of acute rejection. A major challenge in the application of current immunosuppressive agents is the narrow therapeutic window between efficacy and toxicity. In attempts to minimize toxicity, multiple studies have sought to minimize or eliminate specific therapeutic agents, most commonly steroids. The goal of the transplant process has been to reduce or eliminate the risks of immunosuppression without jeopardizing graft function (Steiner and Awdishu). Although the role of glucocorticoids in renal transplantation may help protect against kidney rejection, they can also cause detrimental effects, such as worsening of bone mineral density and increased risk of fractures, increased risk of infections, hypertension, and diabetes.  Recent studies have found that steroid avoidance is possible with good results with respect to acute rejection and long-term graft survival (El-Faramawi, et al). Based on the medical literature cited above and the associated concerns regarding long-term steroid use as well as the patients history of osteopenia, hypertension and gestational diabetes, it is reasonable and medically necessary that she undergo a steroid-free renal transplant. All told, the medical necessity of the requested services has been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is a recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population (Nelson, et al). Furthermore, delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, hepatitis C treatment is needed, and Sovaldi with Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested oxygen therapy, light/energy treatment, immune system dysfunction treatment, impaired detoxification treatment, mitochondrial dysfunction treatment at the cellular level and alternative cellular level treatment and intravenous therapy for treatment of her squamous cell carcinoma of vulva.  Findings:  Three physician reviewers found that the submitted documentation and relevant literature fails to support the requested services. The requested services are unproven and not within the generally accepted professional standards of care in the medical community. Furthermore, a review of the medical literature revealed a lack of clinical trials in regards to the requested services showing benefit. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested services are not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested continued residential treatment center services for the enrollees major depressive disorder, moderate, recurrent, and posttraumatic stress disorder. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting as community interventions are thought to offer optimization of treatment gains.  However, individuals with anxiety and mood symptoms coupled with the burden of past abuse and strained family dynamics may require treatment in a more restrictive setting.  In this patients case, she has a history of anxiety and mood symptoms with recurrent suicidality, coupled with limited coping skills.  Like many other children of abuse, this patient lacks an internal locus of control and the ability to self-soothe, and this is compromising her developmental task of identity formation.  Per the submitted documentation, she has failed outpatient treatment and required acute care services on two separate occasions.  Currently, she is enduring mood and anxiety symptomatologies with somatic complaints while struggling with self-esteem and abandonment issues.  She also displays attention seeking behavior and entertains frequent thoughts of self-harm.  On the date indicated, both her antipsychotic and sleep medications were increased.  Per the medical records, she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  All told, continued residential treatment center services from the date specified and forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of scar revision. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees suprapubic keloid scar.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthognathic surgery (CPT 21147, CPT 21123, and CPT 30140 for treatment of this enrollee, who has been diagnosed with maxillofacial skeletal deformity. Findings:  The physician reviewer found that there is sufficient support for the requested procedure in this clinical setting. The submitted documentation supports that this patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. This patient has well documented symptoms associated with her maxillofacial deformity. She reported that she has difficulty chewing and breathing. The provider noted that conservative therapies failed to correct the patients condition. Therefore, in this patients case, orthognathic surgery (CPT 21147, CPT 21123, and CPT 30140) is medically necessary for treatment of this patient. With regards to whether the requested procedure is considered reconstructive in nature, the records reveal that this patient has well documented maxillofacial skeletal deformity.  The etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional, and degenerative problems. The requested orthognathic surgery will improve function and create a more normal appearance in this patients case. The orthognathic surgery will result in improved musculoskeletal and dento-osseous relationships.  Moreover, this procedure will allow improvements in mastication. For these reasons, orthognathic surgery (CPT 21147 and CPT 30140) is reconstructive in nature and not cosmetic.  Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in oral facial and maxillary 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 female enrollee requested residential behavioral health services for medical treatment of her opioid dependence.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient was not at risk for imminent withdrawals. Her medical conditions were stable. Although in need of structure for recovery from her substance abuse, she did not require 24-hour supervision at residential level of care. Suboxone induction and maintenance is routinely performed on an outpatient basis. She had no significant impairments that could not be managed at a lower level of care such as intensive outpatient or outpatient levels of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested Flector 1.3% patches for the treatment of her chronic back pain. Findings:  The physician reviewer found that there was no documentation provided necessitating use of the Flector Patch for the treatment of the patients chronic back pain. The medication is specifically indicated for acute pain due to minor strains, sprains, and contusions. There is no indication in the literature for its use in the treatment of chronic pain. The patient has lumbosacral spondylosis without myelopathy and bursitis. There are other treatment options (tricyclic antidepressants, anticonvulsants, muscle relaxants, and low dose narcotics) available for the treatment of chronic back pain. The patient might benefit from a formal pain management evaluation to determine the best course of treatment for her chronic back pain condition. Furthermore, the patient does not have an intrinsic swallowing defect for which she cannot take oral medication. Thus, the submitted evidence does not establish that Flector 1.3% is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male has requested an for evaluation of his right shoulder strain.  Findings:  The physician reviewer found that this patient presents with a history of right clavicle pain.  He has no history of recent trauma but does have a prior right clavicle fracture that radiographically is well healed.  Clinically, there is no evidence of infection or occult fracture.  The patient has been diagnosed with shoulder strain.  In this clinical setting, a trial of conservative therapy, including 4 to 6 weeks of non-steroidal anti-inflammatory medications (NSAIDs) and activity modification, which can include physical therapy or a home exercise program, is medically appropriate.  An MRI of the shoulder is medically appropriate if there is clinical concern of a rotator cuff tear, impingement syndrome, or a labral abnormality, per American College of Radiology guidelines.  In this patients case, there is no clinical evidence of a suspected rotator cuff tear, impingement syndrome, or labral abnormality.  All told, the requested MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections every 10 weeks, or in the alternative, Botox injections every 12 weeks. The American Headache Society (AHS) recommends preventive treatment when migraine attacks significantly interfere with a patients daily routine despite acute treatment, a patient has four or more attacks per month, or a patient has contraindication to, failure, or overuse of acute treatment. Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. In 2016, the American Academy of Neurology (AAN) updated its guidelines to include Botox for the management of chronic migraine, which is defined as attacks lasting four or more hours on at least 15 days each month for three months. Botox has been demonstrated to be safe and effective to increase headache-free days. In this case, the patient has a history of chronic migraines that have not responded to multiple oral preventative medications. Based on the AHS statement and AAN guideline, this patient is an appropriate candidate for prophylactic treatment with Botox therapy. The records demonstrate that the patient has maintained fewer and less severe migraines with use of Botox since 2017. The patient has experienced clinical improvement with Botox therapy. Moreover, Botox dosing every 12 weeks is consistent with current medical literature and guidelines. Given these findings, the requested Botox injections every 12 weeks are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.