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

The patient is a 44-year-old woman with a body mass index (BMI) of 48.7. The patient has multiple comorbidities including gastroesophageal reflux disease, high cholesterol, and arthritis. The Health Plan has denied authorization for gastric bypass with duodenal switch indicating that the safety and efficacy of the duodenal switch procedure has not been established in peer-reviewed literature. With a BMI of 48.7 and comorbid conditions, the patient is an appropriate candidate for consideration of weight loss surgery. In general, duodenal switch has been indicated for patients with a BMI of greater than 60. A recent study supports duodenal switch in a broader range of patients. However, there is no compelling evidence that duodenal switch is necessary for this patient. The patient can be safely and effectively treated through Roux-en-Y gastric bypass. Although the patient takes NSAIDs for treatment of arthritis, she will still be able to use NSAIDs following Roux-en-Y gastric bypass as the amount of acid in the pouch is significantly reduced. Furthermore, her analgesic needs should be significantly reduced by weight loss following Roux-en-Y gastric bypass. Based upon the information set forth above, I have determined that the requested duodenal switch procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. However, if the patient requests authorization and coverage for Roux-en-Y gastric bypass the Health Plan should authorize the procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested HCPCS code J9310, rituximab injection and CPT code 96365, intravenous infusion for therapy, prophylaxis, or diagnosis, initial up to one hour, and 96366, intravenous infusion for therapy, prophylaxis, or diagnosis, each additional hour for treatment of her medical condition.  Findings:  The physician reviewer found that this patient presented with multiple sclerosis, with ring enhancing lesions. She reportedly stabilized with Rituxan previously.  The records do not indicate trials of any other multiple sclerosis disease modifying agents. These are well-studied and U.S. Food and Drug Administration (FDA) indicated medications for the management of multiple sclerosis.  The trial data for use of Rituxan for multiple sclerosis is not of similar scientific quality.  All told, the requested services are 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 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: A 29-year-old female enrollee has requested authorization and coverage for eye movement desensitization reprocessing (EMDR) for treatment of the enrollees post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that The patient has not demonstrated evidence of danger to self or others. She endorsed decreased anxiety and depression, improved sleep and appetite, her nightmares had ceased, and she had returned to work. She was learning coping skills to deal with others and move forward. She completed group therapy on 8/24/17. Overall, the records do not demonstrate the symptom complex of PTSD. All told, the requested EMDR is not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested service is 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gluteal augmentation and hand feminization. The submitted documentation fails to demonstrate the medical necessity for the requested services. World Professional Association for Transgender Health (WPATH) notes that certain procedures, including fat transfer (specific mention made of buttocks, but not hands) may be medically necessary on a case-by-case basis. A search of the available literature reveals a lack of studies of hand or gluteal feminization outcomes for transgender women. In this patients case, the referral letter from her primary care provider is cursory. Additionally, the letter from plastic surgeon is somewhat vague with regards to approach and expected outcome. The records do not include a detailed plan which clarifies the source of fat for each location. The submitted records do not include a referral letter from a mental health professional indicating that an assessment and discussion of realistic goals and expectations were performed. All told, the requested gluteal augmentation and hand feminization are 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 emergency medicine with expertise in transgender medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old male with HIV-positivity since 1990. Review of the submitted medical records and photographs indicates the patient has developed moderately severe facial fat loss as a result of AIDS and the side effects of AIDS medications. The patient indicates he has had difficulty carrying out his job as a nurse due to his facial wasting. He wishes to undergo a malarplasty to correct the facial wasting. The Health Plan has denied the request indicating that the requested procedure is not medically necessary for treatment of the patients condition.Highly active antiretroviral therapy with protease inhibitors can result in facial lipoatrophy, which is demonstrated in this patient. Surgical intervention to improve this condition is not medically necessary. There is no physiologic or functional benefit to midfacial infra/submalar fat. Furthermore, the indication for restoring a normal appearance depends upon the degree to which the existing state represents a departure from normal. In the case of this patients midfacial lipoatrophy, the departure from a normal appearance is cosmetic in nature. Moreover, there is a scarcity of literature regarding large-scale studies for malar augmentation for AIDS-related lipodystrophy. One study of nine patients and another of five patients demonstrated good results at one to two-year follow-up. However, whether the procedure will result in more than a minimal improvement in appearance remains open to question. There are also inherent risks of elective surgery in the setting of AIDS.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested authorization and coverage for Boniva (J1470) injections for treatment of the enrollees osteopenia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested Boniva injections.  Osteopenia is treated with Vitamin D and supplemental calcium and can be treated with bisphosphonate therapy.  Bisphosphonates inhibit osteoclast-induced bone resorption.  They increase bone density significantly and reduce the incidence of both vertebral and nonvertebral fractures.  Bisphosphonates can be administered orally or intravenously.  The oral preparations can cause esophagitis and are not appropriate for patients with a history of hiatal hernia, severe gastroesophageal reflux or peptic ulcer disease.  Boniva is medically appropriate for the treatment of osteoporosis.  However, this patient has a diagnosis of osteopenia.  Boniva injections are not indicated for the treatment of this condition.  Of note, the patient has osteopenia of the hip, and the medical literature indicates that Boniva reduces the risk of vertebral fractures, but not nonvertebral fractures.  All told, Boniva (J1470) injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the durable medical equipment (DME) devices provided for treatment of the enrollees bilateral articular cartilage disorder, bilateral capsulitis of the temporomandibular joint and temporomandibular sounds on opening and closing of the jaw. Findings: The physician reviewer found that there are multiple types of orthopedic devices used for treatment of temporomandibular disorders (TMD). The medical literature demonstrates that the use of orthopedic appliances reduces TMD symptoms. Anterior positioning appliances or anterior repositioning appliances are used to treat joint pain and noise and any associated muscle pain. According to Leeuw and Klasser, The primary indication for anterior positioning appliance therapy is acute joint pain associated with disk displacement with reduction. In general, these devices should be used on a short-term basis and their use reduced once symptoms have improved, as long-term mandibular repositioning can result in irreversible changes to occlusion and possible internal temporomandibular joint changes. In this case, the documentation supports that the use of an anterior repositioning appliance as it is likely to improve the patients symptoms. While two devices may be more convenient for the patient, there is a lack of consensus in the medical literature that supports two devices are superior to one device. As such, two devices are not clinically indicated. Therefore, one DME device provided was medically necessary for treatment of the patients symptoms. Final Result: The reviewer determined that a portion of the devices at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested for endoscopic endonasal minimally invasive tumor debulking for treatment of her brain tumor.  Findings:  The physician reviewer found that given the lack of evidence for the safety and efficacy of the endoscopic removal of petroclival meningiomas followed by a second stage retromastoid approach, the medical necessity of the requested surgery has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this patients case, the records indicate that her condition is stable. There is no indication of suicidal action, plan or intent, and the patient is denying urges to cut herself. There is no indication of psychosis or agitation. She is compliant with the program, and noted to be smiling except when told she could not go home. There is no evidence of risk to others. The records submitted indicate that the patients condition is incompatible with APA guidelines for treating depression and suicidal behavior in a residential setting and such a setting is not supported by the clinical evidence as being the most appropriate one for this patient. It appears that she can be safely and effectively managed in a lower level of care, such as an outpatient setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.  Findings:  The physician reviewer found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Thus, advanced lipoprotein testing was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Two of three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha (evolocumab) SureClick Auto-injector 140 mg/ml, every two weeks. The American College of Cardiology has developed an expert consensus decision pathway regarding the role of non-statin therapies for LDL lowering for management of atherosclerotic cardiovascular disease risk. Alirocumab and evolocumab (Repatha) may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia. In this case, the patient had no intolerance to these drugs and has achieved an LDL level of 43 mg/dL, which is consistent with published guidelines from the American Heart Association and the American College of Cardiology for target LDL levels. There is a lack of randomized clinical trials that demonstrate that further lowering of the LDL level beyond 70 mg/dL or targeting a lower LDL particle number using proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors such as Repatha will improve clinical outcomes. Therefore, Repatha (evolocumab) SureClick Auto-injector 140 mg/ml, every two weeks is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage of a laparotomy for the treatment of abdominal adhesions.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) scan of the chest for treatment of the enrollee, who has a history of a cough.  Findings: The physician reviewer found that the the submitted documentation fails to demonstrate the medical necessity of the requested services.  Lung nodules are one of the few entities where there is general agreement concerning guidelines for further evaluation.  The Fleischner Society is an international, multidisciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest.  This organization has published widely accepted guidelines for the evaluation of incidentally detected lung nodules.  For patients with solid nodules less than or equal to 4 mm in size, these guidelines recommended no follow-up for low-risk patients. For high-risk patients in this clinical setting, the guidelines recommended follow-up at 12 months and if no change, no further imaging is needed.  Based on the records, this patient does not meet criteria for a repeat CT scan.  CT scanning involves the risk of unnecessary radiation exposure.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested CT scan of the chest is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested for breast implant removal and bilateral breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that there are no photos or physical examination to indicate the patient has macromastia or abnormal breast structures such as ruptured implants, infected breast implants, severe capsular contracture, or breast cancer. As noted by Collins and colleagues, pain and overall health were markedly improved in patients with symptomatic macromastia. However, the authors concluded that ideal candidates for the procedure had previously failed conservative treatment with weight loss, physical therapy, special brassieres, and medications.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old male enrollee has requested continued partial hospitalization for treatment of his polysubstance dependence.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  Due to multiple factors and unique considerations, determination of the appropriate level of care and length of stay for patients with severe substance use disorder is a challenging endeavor.  Clinical guidelines and patient placement criteria have been developed to assist with the determination process.  This patient had a long, concerning history of addiction that had impacted all functional domains of living.  By the date indicated, he had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The patient was still experiencing, and being treated for, lingering withdrawal symptoms.  He remained engaged in active treatment, including family sessions and discharge planning.  He was progressing through the status levels of the program.  The current medical evidence supports the services at issue in this clinical setting.  All told, continued partial hospitalization during the specified timeframe was medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a four year-old male who experienced birth asphyxia and acute renal failure, which has persisted in stable renal failure with growth failure are requesting authorization of growth hormone therapy.  Reviewer's Findings: The reviewing physician found that the submitted clinical information indicates the patient is an appropriate candidate for growth hormone therapy based on the documented diagnosis of chronic renal failure and his severe growth retardation.  The physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 20-year-old female has requested approval for esophagoscopy with Botox for treatment of her gastroparesis.   Findings:  Two physician reviewers found that the patient has symptomatic gastroparesis. Per the medical records, she has delayed gastric emptying as documented by Smart Pill study. Her provider noted that the patient did not respond to erythromycin or Reglan. The submitted documentation noted a suboptimal response to Zofran for nausea.  The medical records noted chronic gastroesophageal reflux disease.  In this patients case, the requested esophagoscopy with Botox is not likely to be superior over other available treatment modalities. The management of gastroparesis is difficult, as the standard medications are minimally efficacious and limited by side effects. The current medical evidence has not demonstrated the superior efficacy of esophagoscopy with Botox in this clinical setting.