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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implant of hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System (CPT codes 64568, 0466T and 95970)). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.Findings: There is support in the medical literature for the efficacy of the requested services in this patients case. The U.S. Food and Drug Administration has approved this device for the treatment of OSA. The records demonstrate that this patient has severe OSA and has not been able to tolerate the CPAP device. In addition, the patient had a drug induced sleep endoscopy, which showed anterior posterior collapse and no concentric collapse. Accordingly, with an AHI of 46 and a body mass index less than 32, the patient meets criteria and is a good candidate for the device. As such, implant of hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System (CPT codes 64568, 0466T and 95970)) for treatment of this patients OSA is likely to be more effective than any available standard treatment modality.Final Result: All three reviewers determined the requested services are 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 reviewers are board certified in otolaryngology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block for treatment of the enrollees occipital neuralgia, neck pain, and muscle spasm of cervical muscle of neck.  Findings:  Two physician reviewers found that the records indicate the presence of occipital neuralgia as documented by physical examination findings. Occipital nerve blocks are supported for diagnostic purposes but are not supported for therapeutic treatment as there is a lack of long-term benefit supported by the peer-reviewed medical literature. Researchers reported that there was no long-term improvement of headache of chronic migraine type with use of occipital nerve block. Other researchers found that greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Other researchers noted there was no long-term improvement of chronic migraine with use of occipital nerve blocks. Final Result: The reviewers determined that the service at issue was 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: Reviewer 1 is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. Reviewers 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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

Findings:  The physician reviewer found that The patient has requested reimbursement for bilateral breast implant removal. Swezey and colleagues explain, When evaluating a potential implant rupture, important determinations to make include the makeup of the implant (saline implant or silicone implant), and the length of time the implant has been in place. The authors note, There is rarely pain with a saline implant rupture outside of the infrequent post-traumatic ruptures. The authors further note, Saline implant rupture results in the extravasation of a simple normotonic saline solution that is harmless and will be reabsorbed by the body over time. Tahir and Shamsudeen state, Mastalgia is a medical term used for breast pain, one of the most common complaints among women of 15 to 40 years of age (child-bearing age). Approximately two-thirds of women during their reproductive lives suffer from this condition and seek medical help. It is a dull, aching pain while some women may describe it as heaviness, tightness, discomfort, or burning sensation in the breast tissue, which may be unilateral or bilateral. Most often, it is located in the upper outer quadrant of the breast and can sometimes radiate to an ipsilateral arm. It is most common in premenopausal and perimenopausal women, but postmenopausal women can also rarely develop such pain. The breast pain ranges from mild to severe, could be intermittent or constant throughout the day, and may interfere with the female's quality of life. In this case, the patient reported bilateral, chronic breast pain, indicating mastalgia that may be due to a wide variety of causes and that was not caused by a recent unilateral rupture. While explantation may be appropriate following the rupture of a silicone gel breast implant due to concerns of the residual silicone gel, the rupture of a saline breast implant does not necessitate explantation, as the saline solution is absorbed by the body, and a flat deflated saline implant is as benign to the body as an inflated saline implant. Given that rupture of a saline breast implant presents no risk from the free released saline, which is reabsorbed into the body, the service at issue was not medically indicated. Therefore, bilateral breast implant removal was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old male with malignant paraganglioma. He has a history of metastatic disease and in addition to radiation therapy, has been treated with multiple rounds of chemotherapy. A recent CT scan showed probable liver metastases and new mesenteric lymph nodes. The patients tumor marker (chromogranin A) is also elevated. A PET scan has been requested to re-stage the patients disease and thereafter plan treatment alternatives. The patients request for authorization of the PET scan was denied by the Health Plan based upon a determination that it is not medically necessary.There has not been extensive research on malignant paraganglioma due to its rarity. However, a recent study by Fitzgerald, et al, concluded that combined PET/CT fusion imaging is currently the state of the art for accurately detecting and quantifying paraganglioma metastases.  In the past, PET imaging has been useful in planning the patients treatment. The extent of the metastatic disease needs to be accurately determined at this juncture, in order to plan the next phase of treatment. CT or MR imaging cannot determine the metabolic activity of this patients metastatic disease. PET imaging however, can determine the metabolic activity of the metastatic disease and facilitate the commencement of appropriate treatment planning. Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested facial feminization surgery for treatment of her gender dysphoria.  Findings: The physician reviewer found that upon review of the submitted clinical documentation, the medical necessity of the requested services has not been established. The proposed procedures appear consistent with aesthetic improvement, addressing facial aging and appearance concerns rather than specific gender-related abnormalities. The procedures at issue would be considered treatment of relatively normal structures for the patients age. Thus, the requested procedures would be considered cosmetic enhancement. Although facial feminization procedures may be indicated in some transgender individuals, this determination must be made on a case by case basis. In this patients case, she presents with facial features that are consistent with a female appearance. While the proposed procedures may result in aesthetic improvement and create a more youthful appearance, they are not clinically indicated for the treatment of gender dysphoria. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. With regard to the whether the proposed procedures are considered reconstructive in nature, review of the submitted clinical documentation and photographs does not reflect any abnormalities involving the patients brow position, nose, facial structure, lips, facial hair, hairline, forehead and skin. The patients facial appearance is consistent with the appearance of a female. She has signs of aging which are consistent with the normal aging process. With regard to the patients hairline, although she has significant loss of hair anteriorly, this can be present in females as well males. All told, the proposed procedures do not meet reconstructive surgery criteria for treatment of gender dysphoria.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or considered reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested authorization and coverage for a laparoscopic colon resection.  The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees digestive system/gastrointestinal 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 procedure is not medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 61-year-old female enrollee has requested emergency services and inpatient services for treatment of her gastrointestinal bleed.  Findings:  The physician reviewer found that the patients symptoms on the date indicated met prudent layperson criteria for emergency care.  A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize her health.  This patient presented with rectal bleeding.  She had recently experienced a similar episode requiring transfusion.  A prudent layperson would likely assume that recurrent rectal bleeding would require immediate medical attention.  However, the emergency physician found her bleeding to be minimal.   Thus, the patients condition was stable for transfer in the emergency department prior to admission.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested for inpatient care for treatment of her detoxification. Findings:  The physician reviewer found that the patient showed no signs of imminent withdrawal requiring a detoxification inpatient program. Though she was considered to have evidence of benzodiazepine dependency and withdrawal, no chart evidence or objective data to support this view has been provided.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested substance abuse residential treatment for treatment of his alcohol dependence and major depressive disorder. Findings:  The physician reviewer found that 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 for patients with addictive disorders is a challenging endeavor.  The interpretation and application of clinical guidelines and patient placement criteria falls upon providers working directly with the patient population.  In this particular case, the patient had failed lower levels of care.  He had participated in intensive outpatient alcohol treatment and community-based services only to promptly relapse.  His alcohol consumption dominated functionality and placed both himself and others at risk.  His social setting as arranged had been unable to support his sobriety.  Considering the clinical presentation and peer-reviewed literature, residential placement is expected to improve the patients condition and prevent a more serious episode of illness.  All told, substance abuse residential treatment is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested durable medical equipment in the form of an electric wheelchair for her musculoskeletal condition. Findings:  The physician reviewer found that she has not been able to effectively and functionally propel herself for a number of years.  She is dependent upon caregivers to help her navigate her surroundings via her manual chair.  The patient is not able to propel herself in her wheelchair as her body structure, impaired upper body strength, and the supporting surfaces on her wheelchair make it difficult.  With her current wheelchair, she is not able to perform certain activities of daily living.  Further, her social interactions have been negatively impacted by her difficulties with functional mobility. The current medical evidence supports the requested equipment in this clinical setting.  All told, the requested power wheelchair is 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 pediatrics 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 authorization and coverage for Harvoni 90-400 mg, one tablet daily for 12 weeks for treatment of her chronic hepatitis C virus (HCV) genotype 1b. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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

A 53-year-old female enrollee requested authorization and coverage of gastric bypass "roux-en-Y" surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested pharmacogenetic testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a paucity of evidence for the benefits of pharmacogenetic testing in the context of pain management. The medical literature indicates that many studies investigated a possible role of the CYP2D6 polymorphisms on pain sensitivity, pharmacokinetics and pharmacodynamics of these drugs, but the results of analgesia and adverse effects are conflicting. The authors recommend more studies to demonstrate genetically determined unresponsiveness and risk of developing serious adverse events for patients with pain and these should involve larger numbers of patients in different population types. Clinical treatment of the patients condition is based on ongoing practice standards. Pharmacogenetic testing including CYP2D6 testing is not standard practice regarding management decisions involving pain management therapies and the available medical records provided for review does not support that such testing will alter her treatment from standard available therapy.  Final Result: Three reviewers determined that the testing at issue was 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:   One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  Two reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld

A 39-year-old female has requested laser hair removal for treatment of her pseudofolliculitis and hidradenitis suppurativa.   Findings:  Two physician reviewers found that this patient has insulin dependent diabetes mellitus and has had a diagnosis of hidradenitis supportiva and pseudofolliculitis for four years. The records indicate the patient has been treated with incision and drainage on multiple occasions and oral antibiotics. The abscesses cause her sugars to elevate. She reportedly experienced a serum sickness like reaction to one of the antibiotics. Her provider has recommended treatment with laser hair removal to give her some relief of this chronic disease.  Hidradenitis supportiva is a chronic debilitating disease without any known long-term effective cure. Treatment modalities are largely anecdotal and not based on double blind placebo controlled studies. The provider must consider multiple factors in formulating a treatment approach for his patient based on severity of disease and individual comorbidities. Use of oral antibiotics in combination, rather than in series, can be effective. Hormonal therapy, systemic retinoids, and intralesional corticosteroids are also treatment options. More recently, tumor necrosis factor (TNF) alpha blocking drugs have shown promise in the medical treatment of this disease. Surgical excision has been proven to be effective, but can be associated with scarring. Many types of laser have been described in the treatment of hidradenitis. Publications on hair removal lasers, specifically the long pulsed Nd:YAG laser treatment, do cite some short-term improvement in disease. However, this improvement has not been compared directly to oral antibiotic therapy, which remains the standard of care. Although hair removal may give this patient some relief, it is not likely to be superior to standard available treatments. According to a recent review from Jemec, there is a paucity of data from controlled trials on which to base a treatment plan. Further, the author noted that a direct comparison of surgical techniques is necessary to support an improvement in patient health outcomes. As such, the requested laser hair removal is not likely to provide this patient with equivalent, or superior results, when compared with standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old male enrollee has requested for use of vertebral axial decompression, mechanical traction therapy for treatment of his back pain.   Findings:  Three physician reviewers found that there is a lack of long-term outcomes data to support its use. More data is needed to establish the efficacy of traction for low back pain. There are other therapies that are likely to be more effective in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee requested authorization and coverage of the medication Aciphex for the treatment of severe gastroesophageal reflux disease and severe abdominal pain.  The health plan denied the enrollees request indicating that the requested medication 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 medication is not medically necessary until it is established that an H2 blocker is ineffective.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. The specialized skill, knowledge and judgment of a skilled professional nurse has not been required to safely and effectively provide this patient with medically necessary and reasonable treatment. The patient did not have complex wound care, a tracheostomy tube or other daily SNF level skilled nursing. Based on the patients functional status, the patient did not require services on an inpatient basis, in a SNF setting. All told, the SNF services provided were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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.