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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 3a. The submitted documentation supports the medical necessity of the requested medication regimen. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive; genotype 3 patients should be treated with Mavyret for eight weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg for eight weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iron transfusion therapy. On 07/25/18, the patient did not have symptoms of anemia, such as excessive fatigue or shortness of breath. The patient also did not have laboratory indices of frank anemia. It is notable that the patient had normal iron stores (total iron) and ferritin, which indicate that the patient was not anemic at that time. There is no history provided of trial and failure of oral iron preparations.Chen and colleagues explain that in similar patients with gastric bypass, iron deficiency can manifest as anemia, which occurs in 650% of patients who undergo gastric bypass surgery. Chen and colleagues also stated that oral iron malabsorption may be the primary reason behind the iron deficiency but many patients (up to 50%) may still absorb oral iron normally. Oral iron absorption is not always hindered and patients with borderline iron stores, as this patients, may be adequately supplemented with oral iron. Iron infusion therapy is indicated only for patients with anemia who cannot get the iron they need through oral supplementation. In this case, there is a lack of documentation showing that the patient has tried and/or failed oral iron supplementation. Lab results also do not show that the patient is anemic.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 hematology 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

A 55-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that the laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of 5-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of obesity in the well selected patient such as this patient. As with any weight loss surgical procedure, the patient should undergo appropriate pre-surgical workup including psychological evaluation and documentation of normal TSH level prior to surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries including CPT 30410  rhytidectomy, cheek, chin and neck; CPT 14060  adjacent tissue transfer, eyelids, nose, ears and/or tips (10 sq cm or less); CPT 14021  adjacent tissue transfer, scalp, arms, legs (10.1-30 sq cm); CPT 21139  reduction forehead, contouring and setback of anterior frontal; CPT 21121  genioplasty, sliding osteotomy; CPT 67900 x 2  brow lift; CPT 15773  grafting of autologous fat by liposuction (25 cc or less); CPT 15774 x 4  grafting of autologous fat by liposuction (each additional 25 cc). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. This patient presents with gender dysphoria as noted by her providers in their letters written in support of facial feminization surgery. The patient transitioned to non-binary and was started hormone therapy in June 2018. The patients providers have recommended facial feminization surgery to address the patients gender dysphoria. Based on the WPATH SOC, the requested facial feminization surgeries including CPT 30410  rhytidectomy, cheek, chin and neck; CPT 14060  adjacent tissue transfer, eyelids, nose, ears and/or tips (10 sq cm or less); CPT 14021  adjacent tissue transfer, scalp, arms, legs (10.1-30 sq cm); CPT 21139  reduction forehead, contouring and setback of anterior frontal; CPT 21121  genioplasty, sliding osteotomy; CPT 67900 x 2  brow lift; CPT 15773  grafting of autologous fat by liposuction (25 cc or less); CPT 15774 x 4  grafting of autologous fat by liposuction (each additional 25 cc) 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 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

A 47-year-old male enrollee has requested for Azor 5mg/20mg for treatment of his condition. Findings:  The physician reviewer found that with suboptimal blood pressure control on single therapy, there are several drug classes that have been used with success. These include diuretics, ace inhibitors, and calcium channel blockers which have been used successfully in dual therapies as a second tier blood pressure control agent. These medications are medically acceptable therapies within the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of his chronic hepatitis C virus genotype 4. Findings:  The physician reviewer found that according to 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. This applies regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 4 patients, based on the ASTRAL-1 trial, which showed 100% cure rate. Delay in treatment may result in decreased survival. 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: Upheld

The patient is a 38-year-old female who is 57 tall and weighs 165 pounds. She had a gastric bypass in November 2003 with preoperative weight at 298 pounds. She lost 130 pounds subsequent to the surgery and her weight is now stable. The patients provider indicates the patient is concerned about excess skin at her abdomen, especially on the hypogastrium. This is occasionally associated with the sweating and rashes, especially in the summer months. She also dislikes the excess skin at her inner thighs. She also notes that she has had significant buttock pain since losing a lot of weight and notes that she gets soreness on the ischial bones when sitting on poorly cushioned seats. The patient was evaluated by a plastic surgeon for these complaints in December 2005. The surgeon noted no hernia and no active rashes. He found ptosis of the lateral thighs and both buttocks and upper and lower abdominal aprons of fat with excess vertical and horizontal skin. He recommended circumferential torsoplasty, abdominoplasty or simple panniculectomy.  A medial thigh lift was also discussed.  The office notes from the patients primary care provider span the time period of September 2005 through January 2006 and do not mention any patient complaints related to the above abdominal/torso issues.   The patients request for authorization of the torsoplasty was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The photos provided do demonstrate a hanging pannus. However, there is no documentation of a chronic or recurrent skin condition associated with the pannus. The providers notes do not show a chronicity of skin complaints or outline any medical therapies prescribed for such a condition.  The photographs provided do not illustrate the skin conditions described by the patient.  The record does not include documentation of any medical condition sufficiently significant to require medical treatment. The requested procedure falls within the definition of cosmetic surgery, and would be an alteration of a normal body structure to improve appearance.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anterior segment optical coherence tomography (OCT) services. The standard therapy for this patient with glaucoma suspicion is comprehensive ophthalmologic examination with the addition of gonioscopy to evaluate the anterior chamber angle. Anterior chamber OCT has been reviewed and assessed for its usefulness by the American Academy of Ophthalmology (AAO). Although the AAO did not take a final position on the usefulness of this imaging, the Technology Assessment committee concluded that there have been no appropriately powered longitudinal clinical studies demonstrating that imaging can be used to predict the future development of primary angle closure (PAC). Overall, reviews of the current literature suggest that further studies are needed to clarify whether the anterior segment OCT findings are useful for glaucoma management. Thus, the anterior segment OCT services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the anterior segment OCT services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the anterior segment OCT services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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

The father of a 4-year-old male enrollee who requested authorization and coverage of the medication Lamisil. The health plan denied the request, indicating that the requested medication is not medically necessary for treatment of the enrollees candida/fungal infection.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested for skilled nursing facility services for treatment of his condition. Findings:  The physician reviewer found that the patient needs to do daily exercise to maintain or improve his current level, but this does not require daily physical therapy and occupational therapy. It does require a daily exercise regimen. He does not have daily skilled nursing needs.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested for Nuvigil 150 mg for treatment of her multiple sclerosis and stated diagnosis of fatigue. Findings:  The physician reviewer found that the medical records do not describe symptoms of fatigue in this patient, nor do they reflect the use of any other medications for the management of fatigue. Nuvigil (armodafinil) is the R-enantiomer of modafinil. There is some evidence in the available peer-reviewed medical literature that armodafinil and modafinil can be of benefit in the off-label treatment of fatigue in conditions such as MS. A study by Brown and colleagues noted, based on the available data, use of modafinil for the treatment of MS-related fatigue has demonstrated benefit in all uncontrolled studies but has conflicting results from two controlled studies. The authors concluded, larger, long-term, randomized controlled studies are necessary to further elucidate the appropriate dose of modafinil, its effects on MS-related fatigue, and adverse effects associated with its use. Additionally, there is no evidence in the provided records that this patient has inordinate fatigue, or that standard treatments for fatigue, such as amantadine, have been tried without success. Therefore, the use of Nuvigil is not medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only. Final Result: The reviewers determined that the diagnostic procedure 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. The 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

The parent of a 6-year-old female enrollee has requested occupational therapy two times per week for treatment of the enrollees developmental coordination disorder. Findings:  The physician reviewer found that Smits-Engelsman and colleagues concluded that both occupational and physical therapy interventions produced benefit for motor performance in children with DCD.  Peens and colleagues also noted that intervention programs improved motor proficiency and self-concept for children with DCD and emphasized the potential for emotional dysfunction if DCD was not treated. For the reasons stated above, occupational therapy is a medically appropriate and necessary intervention for this patient with DCD. However, based upon the submitted clinical documentation, once weekly OT is sufficient to address the patients motor coordination/sensory processing deficits. As such, OT one time per week is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

 A 39-year-old male enrollee has requested the ClariVein procedure for treatment of his medical condition. Findings:  Two physician reviewers found that review of the submitted clinical documentation does not demonstrate that the services are likely to be of greater benefit to this patient than conservative treatment options.  Per the submitted documentation, the patient does not appear to have complaints related to superficial venous incompetence.  The records indicate that the patient is asymptomatic and has no sequelae of venous insufficiency.  Additionally, the treatment notes do not document prior conservative therapy.  Thus, there is a lack of support for the requested services in this clinical setting. Absent documentation of symptomatology that has failed to respond to conservative treatment, the patient is not an appropriate candidate for the ClariVein procedure at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: This is a patient who has a history of osteoarthritis (OA) and bilateral knee pain. The patients records from a physical medicine specialist, note the left knee with no effusion, normal motion and tenderness to the lateral and medial joint line of the left knee, and viscosupplementation (hyaluronic acid under brand names such as Orthovisc) being recommended. The orthopedic surgeon reports that the patient has benefited from viscosupplementation after oral medication was unsuccessful in relieving her knee pain. The patient also reports benefit from prior knee injections. At issue is whether the requested Gelsyn-3 injection series in the left knee (J7328) is medically necessary to treat the patients medical condition. The reviewer stated that literature reports that viscosupplementation injections to the knees can be helpful for pain reduction in patients like this one, with OA. Studies have shown that this may help delay the need for a total knee replacement surgery. Although additional records to note the patients response to the latest injection(s) were not provided for review, it is apparent from the medical records that this patient has received benefit from viscosupplementation. Literature review notes that hyaluronic acid injections may delay the need for knee surgery and may be of value.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an eight-month-old female enrollee requested authorization and coverage of the medication Synagis. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.