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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc-One injection in the left knee. Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of good relief of knee symptoms with prior viscosupplementation. Furthermore, the patients remaining treatment options are limited to total knee arthroplasty. The patient has tried and failed other conservative treatments including cortisone injections. For these reasons, the requested Synvisc-One injection in the left knee is 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her medical condition.  Findings:  The physician reviewer found that this patient was admitted to the residential treatment center (RTC) care with a history of a mood disorder and borderline personality disorder. She also presented with a history of substance abuse and an eating disorder however during the admissions at issue she did not require the intensity of services provided in a 24-hour facility. At the time of admission on the date in question, she was not showing any severe mood symptoms. Throughout this course of treatment, she was not showing any suicidal or homicidal thoughts, plans or intent. For these reasons, the services provided during the timeframe at issue have not been established as medically necessary for management of this patients condition as she was a candidate for evaluation for treatment at a lower level of care at the time of admission.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xiaflex injections (collagenase from clostridium histolyticum). In a systematic review of injection therapies for patients with Peyronie's disease, Russo and colleagues reported that there was evidence for improvements in penile curvature with clostridium histolyticum (brand name Xiaflex). In this case, the patient has a diagnosis of Peyronies disease. Given that surgical treatment would be reserved for cases in which medical management and Xiaflex therapy have failed, the requested services are medically indicated. Therefore, Xiaflex injections (collagenase from clostridium histolyticum) are medically necessary for the 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 urology 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 55-year-old male enrollee has requested for Provigil for treatment of his condition. Findings:  The physician reviewer found that the documentation does not demonstrate that the patient has exhausted more regular avenues towards therapeutic gain. The current dose of Remeron is also quite high.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a magnetic resonance imaging (MRI) of the head/brain with constructive interference steady state (CISS) sequences and cerebrospinal fluid (CSF) flow through the aqueducts for evaluation of the enrollees possible aqueductal stenosis.  Findings:  The physician reviewer found that while this patient does not appear to have evidence of increased intracranial pressure based on a single static neuroimaging measurement, the growth and attainment of neurocognitive and motor milestones is largely dependent on the health of oligodendrocyte maturation/myelination during the first one to two years of postnatal life. A single head computed tomography (CT), while reassuring for no evidence of active hemorrhage, is inadequate to evaluate CSF flow dynamics, which in turn reflect the overall health of developing white matter. Thus, the requested MRI scan of the head/brain with CISS sequences and CSF flow through the aqueducts for further evaluation is medically necessary for evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatric 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

The patient is a 56 year old male that underwent surgical closure of a skin cancer defect in January 2006. He requested a scar revision almost immediately following surgery.  Photographs dated May 2006 show a well-healed flap with obliteration of the upper part of the nasojugal fold. At issue is whether surgical scar revision is medically necessary for treatment of the patients condition.Scar revision is not medically necessary for this patient.  His flap has healed well and the records do not document any problems with infection, pain or persistent edema. The submitted photographs show a healed flap without significant scarring or edema. The nasojugal fold is indistinct in the area of the flap, but the patient is only five-months postoperative, and this contour may improve in time.  Most plastic surgeons recommend a waiting period of one-year prior to performing scar revision to allow all inflammation to resolve. The aesthetic result of this patients reconstruction is already quite good and should improve over the next several months.  There is no evidence the reconstruction is causing any functional problems. Accordingly, 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: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of enzyme potentiated desensitization. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees anaphylaxis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested excision and biopsy of a right breast mass for treatment of the enrollees gynecomastia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Gynecomastia is considered a normal variation of puberty and typically spontaneously regresses within 18 to 24 months. If adolescents have surgical therapy before completion or at near completion of their puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence (Cakan and Kamat). A standard system used to describe the normal development of puberty and determine if an adolescent is at or near completion of puberty is the Sexual Maturity Rating (SMR), Tanner stage. The Tanner scale (also known as the Tanner stages) is a scale of physical development based on external primary and secondary sexual characteristics. It assigns a stage value to breasts, genitalia and pubic hair of between I and V which is complete adulthood. Completion of the Tanner stage V milestones typically signifies the end of puberty. The use of surgical excision for treatment of gynecomastia in patients under the age of 18 or in those who are not yet at least 18 months after the end of puberty is not considered an acceptable alternative to non-surgical forms of treatment. Therefore, gynecomastia excision and biopsy is not clinically indicated in this patient unless and until the gynecomastia persists past puberty or Tanner stage V. As such, the medical necessity of the requested services has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for BRCA Panel Plus genetic testing. As noted in the medical literature and National Comprehensive Cancer Network (NCCN) guidelines, BRCA1 and BRCA2 genes are important to test in the setting of a first degree relative with ovarian cancer (Daly, et al.). According to the NCCN guidelines on criteria for genetic testing when suspected to have hereditary breast and ovarian cancer, the patients records should document a first or second degree relative who meets any of the personal history requirements with epithelial ovarian, fallopian tube, or primary peritoneal cancer diagnosis at any age. Based on the NCCN guidelines, this patient meets the criteria to qualify for the BRCA1 and BRCA2 gene testing based on her first degree relative in her sister with ovarian cancer at age 30. In this clinical setting, the performance of genetic testing with BRCA Panel Plus, was consistent with the current recommendations from the NCCN. Accordingly, BRCA Panel Plus genetic testing was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the BRCA Panel Plus genetic testing was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology and is 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 patient is a 35-year-old man who has been prescribed Elidel to treat intertriginous dermatitis of the groin. The patients provider is concerned that treatment with steroids could cause atrophy and permanent damage. The Health Plan has denied authorization and coverage for Elidel on the basis that it is not medically necessary.Elidel is an effective treatment for many skin conditions including atopic dermatitis, eczema, intertriginous dermatitis, and allergic contact dermatitis. This topical medication does not have the side effects of topical corticosteroids, namely telangiectasis and possible permanent skin atrophy. The side effects of systemic corticosteroids have been reported with the use of topical corticosteroids due to percutaneous absorption. Elidel is more effective and safer than topical steroids particularly since intertriginous areas have the potential for a high degree of systemic absorption. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 66-year-old female enrollee has requested Botox injections for treatment of her neck pain.  Findings:  Two physician reviewers found that the patient has chronic left neck pain with elements of torticollis and muscle shortening.  She has responded to previous Botox injections. Although her condition may have elements of myofascial pain, there are also elements of torticollis. The benefit of Botox therapy for the treatment of torticollis is acknowledged by the Health Plan. Given the patients clinical history and the failure of more traditional therapies, further treatment with Botox is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested Epivir for treatment of his HIV. Findings:  The physician reviewer found that the current medical evidence does not support the patients desired interruption of his antiviral therapy. There is significant increase in mortality in patients who have interruptions of antiviral therapy as compared to patients who remain on antiretroviral therapy. This patient is at increased risk of having a resistant HIV strain as a result of prior use of Epivir as a single agent.  The submitted medical documentation fails to demonstrate the medical necessity of the requested medication. All told, Epivir is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. This patients case illustrates one of the important values of digital breast tomosynthesis in that the technique often allows the radiologist to subtract out dense glandular elements of the breast from underlying architectural distortion which in turn could reflect an early infiltrating cancer. The advantage is due to the tomographic nature of digital breast tomosynthesis.  Sometimes, as in this case the appearance of the breast on tomosynthesis alleviates the need for ultrasound as a separate examination. Therefore, the breast tomosynthesis was likely more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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 lab work  Based on current publications, there is not enough clinical data or randomized controlled trials demonstrating its use for initiating therapy or making clinical decisions. The American College of Rheumatology (ACR) does not support the use of this testing for evaluation in this clinical setting. These tests include patient input, tender/swollen joint counts and other biomarkers to determine disease activity. In this case, there are multiple lab tests, but no recent history, examination or clinical findings to determine the patients current disease activity. As such, the lab work was 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 lab work was not likely to be more beneficial for treatment of the patient's 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 subspecialty certification in rheumatology 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 patient has requested authorization and coverage for lidocaine infusion therapy in an inpatient hospital setting. This patient presents with erythromelalgia, which is characterized by erythematous, warm, painful extremities. The patient has tried and failed multiple pharmacological agents for her neuropathic pain. The records document that her condition is interfering with her ability to perform activities of daily living. Medical literature states that recent investigations have identified sodium channelopathy as a genetic cause for this condition, classified as primary inherited erythromelalgia. The authors noted that although there is a lack of standard therapies for the management of pain related to erythromelalgia, lidocaine has been used with success in this clinical setting. Therefore, treatment in an inpatient hospital setting is appropriate. Based on the current medical literature, the requested lidocaine infusion therapy in an inpatient hospital setting is 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 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: Overturned

The patient is a 38-year-old female who is 59 weighing 316 pounds with a body mass index (BMI) of 46. She has tried multiple diets without success. The patient would like a consultation with a bariatric surgeon to determine if she is an appropriate candidate for weight loss surgery. The Health Plan has determined the requested consultation is not medically necessary for evaluation of the patients condition.The patient is morbidly obese with a body mass index of 46. She has failed multiple attempts at weight loss surgery. The patient meets nationally accepted criteria for consideration of weight reduction surgery. The requested consultation is medically indicated to help determine if surgery is an appropriate treatment modality for this patient. Therefore, I have determined the requested consultation is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patients Clinical Institute Withdrawal Assessment (CIWA) score was a 6 on admission. She appeared to have adequate ability to tolerate and cope with withdrawal discomfort. The patient has Ehlers-Danlos syndrome and thyroid disease. These conditions were stable and there was no concern that symptoms would interfere with her recovery treatment. The patient has an eating disorder, anxiety, depression, post-traumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD). She has not been suicidal or homicidal. There is no psychosis. She was able to perform activities of daily living and participate in groups. She has been intermittently compliant with medications in the past. The patient was willingly engaged in treatment as a proactive participant. She was aware of her addiction problem and expressed that she is committed to changing her substance use and adhering with psychiatric medications. The patient has undergone repeated treatment episodes with little positive effect on her level of functioning. She experienced cravings that were managed with naltrexone. The patient lives alone and she indicated that she removed alcohol from her home. She demonstrated motivation and willingness to obtain a positive social support system. Her family is supportive, but does not live nearby. Given these findings, the patient did not meet the criteria for biomedical conditions and recovery environment. Therefore, the RTC services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 with expertise in addiction 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.