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 a high frequency chest wall oscillation (HFCWO) system. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees bronchiectasis.At issue in this case is whether the requested high frequency chest wall oscillation system is medically necessary for treatment of the enrollees medical condition.Bronchiectasis is a disease where the airways become inflamed and dilated, thus creating a fertile breeding ground for bacterial infections. Patients with bronchiectasis typically have a chronic cough and recurrent infections. Treatment for this includes antibiotics, hyperosmolar agents, anti-inflammatory agents and chest physical therapy. The goals of treatment are to reduce the number of exacerbations and to improve the patients quality of life.Researchers concluded that the HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physical therapy. This patient, based on the medical records, has obviously benefited from using HFCWO. It was documented the patient had a cough of two years duration prior to starting chest physiotherapy.  Patients with bronchiectasis have very thick mucous and difficulty clearing mucous. Chest wall oscillation therapy greatly improves the ability to do so. The benefits of the therapy are proven. Additionally, using HFCWO vests allows patients to be independent and provide therapy themselves, at their convenience. This is especially important when patients do not have other family around to provide traditional chest physical therapy. The medical records support the medical necessity of the requested high frequency chest wall oscillation system for this patient.Final Result: The reviewer determined that the requested device 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 subspecialty certification in pulmonary disease 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 64-year-old female enrollee has requested for hemi-implant arthroplasty for treatment of her condition.   Findings:  Two physician reviewers found that Hemi-implant arthroplasty is experimental for the treatment of hallux limitus. The standard of care is a cheilectomy or a joint fusion procedure. There are no long-term outcomes studies to support this procedure. The efficacy and complications in the long-term remain unknown.
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 according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing decreased survival with delayed treatment. Although AASLD/IDSA guidelines do not substantiate concerns over the interaction of Viekira Pak with abacavir/lamivudine, the patient should be considered ineligible for Viekira Pak/ribavirin due to his history of anemia with ribavirin in the past coupled with ongoing chronic kidney disease.  For these reasons, the requested course of Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested for neurological testing and sleep therapy for treatment of the enrollees Celiac disease. Findings:  The physician reviewer found that a review of the submitted records indicates that the testing requested by the patients physician was not limited to that of intelligence testing or the evaluation of learning disabilities alone. The physicians concern was cognitive difficulties and multiple neurologic problems related to Celiac disease. The latter might logically incorporate the psychological evaluation of a potential mental illness, such as, but not limited to, Attention Deficit Hyperactivity Disorder.However, with regard to the sleep therapy services the patient may have received, the submitted clinical evidence does not provide any information documenting a need for such therapy or precisely what the therapy entailed. As such, the medical necessity of sleep therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested a custom anterior cruciate ligament (ACL) brace for the treatment of the enrollees torn cartilage. Findings:  The physician reviewer found that the use of a custom anterior cruciate sparing knee orthotic or brace as recommended by the treating surgeon appears medically reasonable for this patient following surgical reconstruction. Allograft has been demonstrated to have delayed healing potentials and a properly fitted anterior cruciate sparing brace is likely to be protective during this period of time. This young patient is identified in the clinical record as an aggressive sports participant. She will remain vulnerable to recurrent injury but her prognosis improves with use of a custom brace.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested Lap Band surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient does not meet the guidelines set forth by the National Institutes of Health for the requested surgery. At this time, the FDA has approved the Lap Band surgery for patients who meet the criteria set by the National Institutes of Health for weight loss surgery. Weight loss surgery is not indicated for an individual with a BMI that is less than 35. For patients with a BMI less than 35, conservative weight loss methods are standard of care. In this patients case, the requested Lap Band surgery is not medically indicated. All told, based upon the submitted documentation, the requested surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested 24 weeks of Sovaldi and ribavirin for treatment of his chronic hepatitis C virus genotype 3.   Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C 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 is expected to benefit nearly all chronically infected patients. Consistent with the current guidelines, the requested 24 weeks of Sovaldi and ribavirin is medically necessary for treatment of this patients hepatitis C virus. Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed.  Findings:  The physician reviewer found that the patient is asymptomatic who underwent a screening mammogram including tomosynthesis. The exam revealed heterogeneously dense breast tissue. The patient has requested reimbursement for the digital breast tomosynthesis performed. The Health Plan has denied this request as investigational. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms especially in patients with dense breast tissue such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her exam been done with 2D imaging only. Accordingly, the digital breast tomosynthesis performed 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 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: Physician reviewers are board certified in diagnostic radiology 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: Overturned

An enrollee has requested authorization and coverage for a mastectomy (CPT code 19300).At issue is whether the requested mastectomy is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Bellini and colleagues stated, In pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated to a resection under direct vision of the glandular tissue through a periareolar or transareolar incision. The American Society of Plastic Surgeons notes that excision of gynecomastia may be indicated when malignancy is suspected, when grade III or grade IV gynecomastia is present, and when there is pain and discomfort due to the distention and tightness from the hypertrophied breast. In an evaluation of pain, objective physical findings are needed to substantiate the subjective physical complaints. Additionally, fatty breasts do not generally cause the distention and tightness that are caused by glandular hypertrophied from gynecomastia. In this case, malignancy is not suspected. Bilateral breast enlargement is present, which is consistent with pseudogynecomastia in view of the mammography showing that the breasts were almost entirely fatty. Based on the medical information received for review, the patients symptoms are more in line with pseudogynecomastia and not true gynecomastia. Therefore, the requested mastectomy is not medically necessary for the treatment of the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Gynecomastia constitutes an abnormal structure of the body due to a developmental abnormality. In this patients case, mastectomy would be performed to improve function. The surgery will improve function by relieving pain. Accordingly, the requested mastectomy (CPT code 19300) is reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia care she received. Findings:  The physician reviewer found that for this patient, there is no documentation of clinical findings that would have required monitored anesthesia care during her colonoscopy procedure. The patient had an American Society of Anesthesiology (ASA) preoperative physical status classification score of 2, which is deemed as a low risk. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research. Given a low preoperative physical status classification score, this patient did not require monitored anesthesia care. All told, the monitored anesthesia care received was not medically necessary for treatment of the patient during her colonoscopy. Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary for the treatment of this patient.  Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 23-year-old male enrollee has requested transcranial magnetic stimulation for the treatment of his depression. Findings:  The physician reviewer found that the treatment of depression with transcranial magnetic stimulation is relatively recent. It falls into a form of psychiatric therapy called somatic treatment. For several years, the psychiatric literature has reported the development of this procedure. In October 2008, the US Food and Drug Administration determined that it is indicated for the treatment of major depressive disorder in adult patients who have failed to improve following use of one prior antidepressant medication at or above the minimal effective dose and duration. Since this patient has not responded satisfactorily to both Remeron and Prozac, he seems to meet these specific requirements. The records show that the patient has been tried on at least two different classes, since Remeron and Prozac are in different classes. Moreover, the stimulants the patient used constitute adjunctive treatment. Additionally, having two comorbid diagnoses does not necessarily preclude proper treatment of the patients depression by transcranial magnetic stimulation, or by any other approved treatment of depression.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for a face computed tomography (CT) scan for evaluation of her jaw pain.  Findings:  The physician reviewer found that CT scans are extremely useful for revealing skeletal abnormalities of the TMJ. However, the study remains of limited value in soft tissues such as for the evaluation of the disk and capsule, as in this patients situation. As such, the diagnostic procedure at issue has not been established as medically necessary in the evaluation and treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Two physician reviewers found that TMS treatment is not likely to be more effective for this patient than other available options. The U.S. Food and Drug Administration (FDA) has approved TMS for the treatment of treatment resistant depression. In this case, the patient has not been treated with appropriate dosages of antidepressants, nor is there evidence that this patient has been treated with augmentation strategies. Therefore, this patient cannot be considered treatment resistant. Specifically, the medication dosages that have been tried for this patient are low and fall short of the maximum dosages that are necessary to treat a patient with significant depression.  Therefore, there are available safe, standard therapies that are available to this patient that do not appear to have been tried. For the reasons provided, TMS services are not likely to be more beneficial than standard treatments for this patient medical condition. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in psychiatry 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested physical therapy for treatment of her medical condition.  Findings:  The physician reviewer found that the Official Disability Guidelines and American College of Occupational and Environmental Medicine (ACOEM) practice guidelines support the use of physical therapy to instruct patients with low back pain in strengthening exercises. Manual therapy is also supported as beneficial. The guidelines specifically endorse the use of outpatient physical therapy as well as exercise instruction so that patients can independently manage their low back pain. Consistent with these findings, the requested physical therapy is medically necessary for treatment of this patients low back pain.  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 physical medicine and rehabilitation, pain medicine, and occupational 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has Doppler guided transanal hemorrhoidal dearterialization surgery for treatment of the enrollees third degree hemorrhoids. Findings: Two physician reviewers found that Transanal hemorrhoidal dearterialization (THD) is a technique used by colorectal surgeons as one of the treatment options for hemorrhoids. The 2010 American Society of Colon and Rectal Surgeons practice parameters for the management of hemorrhoids describes Doppler guided hemorrhoidectomy as a potential treatment for hemorrhoids and states that larger studies including variations on the Doppler technique and comparisons with other methods with longer follow-up intervals are required before definitive recommendations on this method. However, it should be noted that these practice parameters were published and multiple studies in support of THD have been published since that time. For example, a recent systematic review and meta-analysis was published regarding the clinical outcomes and effectiveness of surgical treatments for hemorrhoids. The authors concluded that THD was associated with less postoperative bleeding and therefore less emergency reoperations as well as decreased postoperative complications, shorter operative time, and decreased pain than standard interventions. All told, the THD procedure was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the procedure at issue was 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 surgery with sub-specialty certification in colon and rectal surgery 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: Urgent Care
Decision: Upheld

The parent of a 21-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that prudent layperson standard defines an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient had been suffering from hemorrhoids for a week. He was not experiencing an acute hemorrhage from his hemorrhoid.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested authorization and coverage for a referral to a pulmonologist for the treatment of restless leg syndrome.  The health plan has denied this request indicating that a referral to a pulmonologist is not medically necessary for treatment 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 referral is medically necessary.