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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a power assist wheelchair. The enrollee has cerebral palsy and generalized muscle weakness. He is mostly wheelchair-bound, is unable to ambulate functionally and uses an ultra-lightweight manual wheelchair for all mobility activities. The enrollee experiences fatigue when using his wheelchair for long distances, and is often stranded due to his level of fatigue and requires family members to pick him up. His internal medicine specialist has requested authorization for a power assist system for the patient. Added to his current wheelchair, the SmartDrive power assist system would give the patient the ability to get himself home safely and reduce the number of total pushes throughout the day; limiting fatigue. The record indicates the enrollee utilizes a manual wheelchair independently and recently received an ultralight-weight wheelchair.  He is able to independently transfer in and out of his wheelchair and perform effective pressure relief.  He continued to possess pain-free range of motion and strength, allowing him to independently self-propel a manual wheelchair.  He shops independently and is able to perform light daily tasks.  He travels independently; either on public transportation or driving his own vehicle.  The enrollee's manual ultralight-weight customizable wheelchair was approximately two months old and in excellent condition. The medical literature indicates how the utilization of power assistance may be effective in reducing potential risk factors. A power assist wheelchair may be indicated for enrollees who are developing overuse injuries, or for enrollees who lack the upper extremity strength to drive a hand-rim wheelchair.  There is no indication the enrollee has developed overuse injuries or does not have sufficient strength to propel a manual wheelchair.  Medical literature indicates requirements for power mobility devices are described as impairments in mobility-related activities of daily living; such as toileting, feeding, dressing, grooming, bathing and travel to customary locations in the home that cannot be ameliorated by a lesser device.  This enrollee has an ultra-light manual wheelchair, which adequately addresses his mobility needs for mobility-related activities of daily living.  There is the indication in the record the power device is being prescribed not to address mobility-related activities of daily living in the home, but rather to help him when he is out and becomes too tired to return home. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine & rehabilitation 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C.   Findings:  The physician reviewer found that the current medical evidence supports the requested medications in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  For this patient, withholding treatment will cause further progression of fibrosis.  All told, Sovaldi and ribavirin for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator implantation. Several studies have evaluated hypoglossal nerve stimulation as a way to improve upper airway stimulation and treat patients with OSA. Researchers found across a multi-institutional study that upper airway stimulation (UAS) therapy showed significant improvement in OSA outcomes. Researchers concluded that improvements in objective respiratory and subjective quality of life outcome measures were maintained at three-year follow-up. Medical literature demonstrated that UAS maintained a sustained benefit on patient reported outcomes on the Epworth sleepiness scale, functional outcomes of sleep questionnaire, and snoring level. Medical literature found that AHI, oxygen desaturation, sleepiness, and functional outcomes were improved with hypoglossal nerve stimulation in patients who failed treatment with CPAP. In this case, the patient has already failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his OSA. Therefore, the requested hypoglossal nerve stimulator implantation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested coronary CT angiography (CTA) for an evaluation of her potential coronary artery disease (CAD). Findings:  Three physician reviewers found that based on the information and history presented there is no indication for CTA at the present time. Limitations in the visualization of the coronary arteries are not uncommon and there remains an overall inability to translate the diagnostic performance of CTA to expected effects on management and health outcomes. The test is not a substitute for cardiac catheterization or nuclear SPECT imaging and the current role CTA is best defined in terms of coronary anatomy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left-sided L3, L4 and L5 radiofrequency ablation.  Findings:  Three physician reviewers found the submitted documentation fails to demonstrate the superior efficacy of the requested services. This patient has multilevel degenerative disc disease with radiculopathy and scoliosis. Performing radiofrequency lesioning in the presence of an extruded disc with radiculopathy, instead of epidural steroid injections or surgery, is not the standard approach. The medical evidence supports surgery after failed conservative therapy. All told, the requested for left-sided L3, L4 and L5 radiofrequency ablation is not likely to be superior over other treatment options.  Final Result: The 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 2.0 mg for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. This patients growth velocity was poor, IGF-1 level was low, and her adult height prediction was more than two standard deviations below her mid-parental target height. Although she did not undergo provocative growth hormone testing, she meets generally accepted criteria for growth hormone treatment. According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum IGF-1 and/or IGFBP-3; and/or other clinical features suggestive of growth hormone deficiency. This patient meets most of the above criteria, and her adult predicted height of 59 inches is short enough to warrant a trial of growth hormone therapy based on current U.S. Food and Drug Administration standards for treatment of idiopathic short stature. All told, Nutropin AQ NuSpin 2.0 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 24-year-old male enrollee has requested SPECT scans for evaluation of the enrollee, who has a history of bipolar disorder and alcohol and marijuana abuse. Findings:  Three physician reviewers found that the current medical evidence does not support the use of the testing at issue in this clinical scenario.  The use of SPECT scans in this situation is not standard of care.  The use of SPECT scans is generally accepted for evaluating and monitoring structural brain disorders, such as stroke, seizures and dementia, heart problems and cancer evaluation.  Thus, the testing at issue was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xifaxin. Findings: Xifaxan has proven to be effective for the treatment of irritable bowel syndrome, diarrhea-predominant (IBS-D). The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D, and the medication has been demonstrated to be safe and effective in randomized placebo-controlled trials. In a study, Xifaxan was demonstrated to be effective, with significant symptom improvement in irritable bowel syndrome. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that rifaximin (Xifaxan) is effective in the treatment of IBS-D. In this case, the patient has been diagnosed with irritable bowel syndrome with diarrhea. Additionally, the patient has previously had good control with Xifaxan. However, the dose requested is not supported. Clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three times daily for 14 days, with up to two additional courses at least 10 weeks apart. Therefore, Xifaxin 550 mg (#60 tablets/30 day supply for ongoing treatment) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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 patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which meets the criteria for medically monitored community based services, as well as high intensity community based services, such as IOP. Given this support, the IOP services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested lipoprotein enzyme immunoassay in the management of cardiovascular disease, homocysteine testing, cardiovascular risk measurement of lipoprotein associated phospholipase A2, high sensitivity C-reactive protein, measurement of small low-density lipoprotein particles and concentration of LDL particles in cardiac risk assessment and management, and apolipoprotein testing for the evaluation of his cardiac risk. Findings:  Two physician reviewers found that this patient has known coronary disease and is status post myocardial infarction and stenting. In this circumstance, treatment guidelines that include lipid evaluation and management have been established, periodically updated by expert committees and endorsed by major national societies. These guidelines currently do not recommend routine performance of specialized lipid tests including lipoprotein-associated phospholipase A2, sub-classification of LDL and homocysteine.  Treatment change or addition based on the results of diagnostic testing at issue has not been shown to improve outcome incremental to that achievable by treatment dictated from standard risk factor and lipid analysis.  In this particular circumstance of known coronary disease, aggressive LDL reduction to less than 70mg/dl is recommended regardless of the results of any specialized lipid analysis.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a breast MRI for an evaluation of her breast discharge. Findings:  The physician reviewer found that a breast MRI can be a useful adjunct to standard breast imaging studies in select patient populations. Breast MRI is used as a screening tool in patients with known BRCA mutation and used as a diagnostic tool in patients with a recent diagnosis of breast cancer. This patient does not have known BRCA mutation and does not have a recent diagnosis of breast cancer. The standard of care in the evaluation of bloody nipple discharge includes diagnostic mammogram, ductography and, at times, breast ultrasound. There is no documentation of a ductogram or attempted ductography, which is the procedure of choice for bloody nipple discharge. Azavedo notes that magnetic resonance galactography remains under investigation and is not the method of choice in evaluating this condition. At this time, the use of breast MRI in the evaluation of bloody nipple discharge has not yet proven to be clinically effective. Therefore, breast MRI was not medically indicated for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested surgical breast augmentation for treatment of her gender dysphoria. The physician reviewer found that the patient presents with gender dysphoria which is a source of significant adverse effect on her mental health. She has been transitioning from the male-to-female gender over the past four to five years. She has been treated with hormonal therapy without adequate breast development. The patient is well-documented to have gender dysphoria. Currently, her examination and photographs depict a lack of breast development and is more consistent with male anatomy. The surgical concept of breast augmentation in male-to-female transgender patients is well-established and documented within the community of plastic surgeons.  According to Weigert and colleagues, Breast augmentation in male-to-female transsexuals is part of gender reassignment surgery. Hormonal feminization might not be sufficient to induce mammogenesis so many patients seek surgery for their chests to resemble the female gender. The authors further state, Through breast augmentation, the male-to-female transsexual patient improves identification with the female gender and therefore is socially integrated. Regarding results, this study supports breast augmentation in this population. In the case of this patient, medical necessity for breast augmentation surgery has been adequately demonstrated in the medical documentation provided for review. Further, the requested procedure is considered reconstructive in this setting. The patient is well-documented to have gender dysphoria; thus her external anatomy should be more consistent with a female than a male. As the patient has failed hormonal therapy, her abnormal breast structure should be considered the result of a developmental abnormality. The requested surgery is intended to create a normal appearance, as her current appearance is not consistent with an adult female. The surgery would attempt to provide a more normal female appearance and is likely to result in more than a minimal improvement. For the reasons stated above, surgical breast augmentation is medically necessary for treatment of the patients medical condition and considered reconstructive in nature.   Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and considered reconstructive in nature. Therefore, the Health Plans denial should be overturned.  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: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 65-year-old male who has been diagnosed with osteoarthritis of both knees. The patient received bilateral knee cortisone injections. It was noted that the patient received three weeks of pain relief from prior cortisone injections. The patient reported bilateral knee pain. Physical examination findings revealed restricted and painful range of motion in both knees. Tenderness was noted over the medial and lateral femoral condyles. The patient received bilateral knee Synvisc One injections. The provider recommended follow-up for repeat Synvisc-One injections in six to nine months. Five months later, it was noted that the patient had experienced significant pain relief with the prior Synvisc-One injections. The patient has requested authorization and coverage for a Synvisc-One injection in both knees. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One injection in both knees is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has had pain relief from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments including corticosteroid injections, with the alternative being total knee arthroplasties. Medical evidence supports the requested services in this clinical setting. Therefore, a Synvisc-One injection in both knees is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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 a similar medical condition.