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

A 36-year-old male enrollee has requested continued residential mental health treatment for treatment of his medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, continued residential mental health treatment during the specified timeframe was not and is not medically necessary. The treatment facility indicates that the patient has previously lost weight in intensive outpatient programs, yet the record indicates that he has not approached that level of success with the residential program. Moreover, the documentation provided for review did not include a treatment plan or an indication of a change of approach with this patient. There is also no indication of a nutritional program or input from a dietician and no mention of a physical rehabilitation program to improve the patients physical strength and ability to exercise. Although the patient is noted to have bedsores, this could be treated by a skilled home health care nurse. While continued residential treatment services were no longer medically necessary, the requested  counseling appointments are medically reasonable and appropriate to address the patients ongoing concerns. Such services are medically necessary to support the patient in his transition from residential treatment and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  Three physician reviewer s found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breast.  In this patients case, her breast tissue was described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, digital breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.   Final Result: Three reviewers determined that the service 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.  Credentials/Qualifications: All three 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The requested services are likely to benefit this patients psychological and social functioning. This patient has a documented history of gender dysphoria and has been through other medical therapies. The World Professional Association for Transgender Health (WPATH) stated medically necessary gender affirming/confirming surgical procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. The Transgender Medicine Model NCD Working Group noted other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women includereconstructive facial feminization surgeryThese procedures are not cosmetic, but rather serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Based on the patients documented history of gender dysphoria, the requested services are medically indicated. Therefore, facial feminization surgeries 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 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 33-year-old male enrollee has requested an RT300 Functional Electrical Stimulation (FES) Cycle Ergometer for treatment of his medical condition, status-post spinal cord injury. Findings:  Two physician reviewers found that the effects of electrical stimulation after spinal cord injury are well known in the medical literature. However, not all patients with spinal cord injury are prescribed this sort of device. In order for such a device to be determined to be appropriate for the patient, it is important to understand the patients present functional level. However, none of this information is provided in the medical records submitted. Detailed documentation of the patients clinical status is essential in order to demonstrate how this device might present an improvement over standard therapies have been attempted previously and failed (if any).In the absence of detailed information regarding this patients present clinical state, his functional status, and what therapies or treatments have been attempted prior to the request for this device, it is not possible to determine that this device is likely to be more beneficial for this patient than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested authorization and coverage for Avodart for treatment of the enrollees enlarged prostate. Findings:  The physician reviewer found that the studies presented in the peer reviewed medical literature have not shown Avodart to be more efficacious than the Health Plans formulary alternative finasteride (Proscar). The patients Health Plan covers Avodart only if finasteride is ineffective or causes side effects. The Health Plans criteria for coverage of Avodart are clinically appropriate and consistent with the standard of care, as the available scientific evidence does not establish that Avodart is clinically superior to finasteride. In this patients case, there is no documentation of any contraindications to treatment with finasteride or that treatment with finesteride has been ineffective. As such, the Health Plans formulary alternative finasteride is appropriate for treatment of the patients medical condition and the requested Avodart is not medically necessary for treatment of his BPH. Thus, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Bravo pH monitoring and manometry tube placement provided on 3/12/20. Current medical literature supports the use of a pH study to evaluate for acid reflux above the lower esophageal sphincter and to confirm the presence of reflux before anti-reflux surgery. Yodice and colleagues note that a thorough pre-operative assessment, including technologies such as pH-impedance studies, is crucial to select appropriate surgical candidates. The authors further note that pH testing is a key test to consider for patients with GERD-like symptoms. Gyawali and colleagues note that endoscopy and pH or pH-impedance monitoring may assist in diagnosing GERD. In this case, the records noted a history of GERD and a hiatal hernia. Following the endoscopy with pH study, the provider recommended hernia repair surgery. In this clinical setting, given the patients persistent symptoms of reflux despite PPI therapy and the presence of a hiatal hernia, the service at issue was medically indicated. Therefore, Bravo pH monitoring and manometry tube placement provided on 3/12/20 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 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

A 40-year-old male enrollee requested authorization and coverage of a power-operated vehicle. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees degenerative joint disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg/100 mg, one tablet daily for a duration of 12 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 is recommended as first-line therapy for treatment-naive or interferon-experienced genotype 2 patients.  A delay in treatment may result in decreased survival.  In sum, Epclusa 400 mg/100 mg, one tablet daily for a duration of 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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

The enrollee requested authorization and coverage for the LINX procedure. The enrollee has a history of gastroesophageal reflux disease. His symptoms include regurgitation, belching, nausea, bloating, and heartburn. The enrollee continues to experience daily reflux. Medications only provide partial relief of his symptoms. The LINX procedure has been recommended for the enrollee. A professional society noted the LINX procedure requires minimal dissection and relatively few technical steps, when compared to Nissen fundoplication. The LINX procedure may provide an option for those with gastroesophageal reflux disease who have not progressed to end-stage disease and its associated complications. The conclusion was the LINX procedure should be an available option to manage those with medication-resistant symptoms. Studies of the LINX procedure showed individuals continued to demonstrate symptom improvement one and two years after the procedureFinal Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for left knee arthroscopic surgery (CPT 29882 and 29881).The patient presented with worsening left knee pain following a sports twisting injury. The patient had diffuse severe pain with associated mechanical symptoms of swelling, popping and clicking. Significant functional limitations in activities of daily living were reported. Clinical exam findings were consistent with imaging evidence of a lateral meniscus tear and potential medial meniscus tear, with mild to moderate chondral wear in all three compartments. X-rays of the left knee showed moderate degenerative changes. Conservative treatment had included activity modification and anti-inflammatory medications. The patient underwent a left knee diagnostic arthroscopy and partial lateral meniscectomy. Current evidence based medical literature supports knee surgery under these circumstances. There was evidence of a traumatic event with onset of severe pain and mechanical symptoms resulting in significant functional limitations. Clinical exam findings were consistent with imaging evidence of meniscal pathology, including significantly positive McMurray's test. Reasonable conservative treatment had been attempted for two months. There was also no evidence of greater than mild to moderate osteoarthritis prior to surgery. Surgery was therefore indicated for functional restoration in this young patient. Accordingly, the left knee arthroscopic surgery (CPT 29882 and 29881) at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for 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: Urgent Care
Decision: Upheld

A 33-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that this patient wanted a medical evaluation to prevent pregnancy following sexual intercourse after the failure of a prophylactic. Despite her history of blood clots, there was no immediate danger to her health. Oral hormone therapy can lower the risk of pregnancy to one or two percent if taken within five days after unprotected sexual intercourse. Oral hormone therapy preparations such as Plan B are FDA-approved and available on an over-the-counter basis. This patient could have been evaluated on a non-emergent basis. While her situation may have warranted a medical evaluation, that service did not need to be provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old male with chronic hepatitis B beginning in April 2004 with a detectable viral count and elevated liver enzymes. As of July 2005, the patient has an undetectable viral count and normal liver enzymes. The patient has been treated with Hepsera for two years and currently his surface antigen is negative. The patient is seeking continued treatment with Hepsera. The Health Plan has denied this request.The evidence regarding whether to continue indefinitely or discontinue Hepsera when a patients viral load is undetectable remains unsettled. Discontinuing Hepsera at this point would place the patient at risk for a relapse. Furthermore, it is standard of care within the gastroenterological community to continue Hepsera in these situations so as to avoid relapses. Therefore, because the evidence remains unsettled and because discontinuing Hepsera would place the patient at risk for a relapse, I have determined the requested therapy is medically necessary for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Genova Diagnostics testing.Findings:  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Multiple evidence based studies have demonstrated that IgG testing to foods is an unproven method of testing for food intolerances as well as food allergy. The Guidelines for the Diagnosis and Management of Food Allergy in the United States, published by the National Institute of Allergy and Infectious Diseases (NIAID), specifically lists allergen-specific IgG4 testing among tests that are unproven and nonstandardized, and therefore not recommended. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is no credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, nor that IgG antibodies cause symptoms. The only exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease. The Genova Diagnostics IgG testing performed for the patient therefore was not likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer number one is actively practicing and is board certified in allergy and immunology and internal medicine. Physician reviewer number two is actively practicing and is board certified in allergy and immunology. Physician reviewer number three is actively practicing and is board certified in allergy and immunology and internal medicine. 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: Experimental/Investigational
Decision: Upheld

A 50-year-old female has requested continued Rocephin IV treatment for treatment of Lyme disease.  Findings:  Three physician reviewers found that Rocephin IV antibiotic therapy beyond four weeks duration is considered experimental/investigational for the treatment of Lyme encephalopathy. Literature reports indicate the benefits of IV antibiotics are short-lived and cognitive impairments return after therapy. To date, there is no convincing, published data that repeated courses of oral or intravenous antibiotics are effective for Lyme encephalopathy. This has been the consensus of the Infectious Diseases Society of America Expect Panel. At this time, there is insufficient evidence to regard chronic Lyme disease or Lyme encephalopathy as appropriate indications for extended IV antibiotic therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Saxenda 3 mg pen injector. Based on current peer-reviewed medical literature, this patient does not meet the criteria for treatment with Saxenda for weight loss or treatment of obesity related comorbidities. Per Lee and Dixon, pharmacotherapy can be a useful adjunct to lifestyle intervention in effecting and maintaining clinically meaningful weight loss. The authors noted that long-term pharmacotherapy for weight loss is appropriate for patients with a BMI of 30 kg/m2 or greater, or patients with a BMI of 27-20 kg/m2 with documentation of obesity related complications. The records provided for review demonstrate that this patient has a BMI less than 30 kg/m2. There is a lack of evidence of obesity related comorbidities to support an indication for treatment with Saxenda. Therefore, the Saxenda 3 mg pen injector received, and future Saxenda 3 mg pen injector, was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 surgery with subspecialty certification in minimally invasive and bariatric 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

The patient is a 44-year-old female with a body mass index (BMI) of 44.8. In addition, the patient has a number of comorbidities including hypertension and diabetes. The patient also reports multiple failed attempts at conservative weight loss. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The patients provider has recommended the patient undergo gastric bypass with duodenal switch. The Health Plan has denied this request.With a BMI of 44 and comorbidities such as hypertension and diabetes the patient meets nationally accepted criteria for consideration of weight loss surgery. There is significant data supporting duodenal switch as an appropriate procedure for this patient. Furthermore, the patient has undergone a full evaluation and it has been determined that duodenal switch is the appropriate weight loss procedure. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.