Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

A 19-year-old female enrollee has requested for an emergency room visit for treatment of her sore throat. Findings:  The physician reviewer found that an emergency medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention would result in placing the members health in serious jeopardy. This patients symptoms had commenced gradually over five days and were not acute in onset. She did report pain, but she did not require pain control in the emergency department. There is adequate documentation that the patient was able to tolerate oral intake and was not in any respiratory distress.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female enrollee has requested bilateral lower extremity endovenous laser therapy (EVLT) for treatment of her bilateral varicose veins. Findings:  Three physician reviewers found that EVLT can be considered for the treatment of perforator veins in appropriate cases as noted by Marsh and colleagues. However, in this patients case, such therapy is not indicated. It is noted in this patients ultrasound report that her veins are being treated to prevent a complication from proposed sclerotherapy treatment. This is not a valid indication for performing EVLT. The records submitted do no indicate any other clinical rationale for why the patients perforators should be treated other than their anatomic proximity to the branches being considered for sclerotherapy treatment. In fact, there is no indication in the submitted documentation that this patient has any perforator reflux, or that these particular perforator veins are enlarged.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services provided for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The determination of level of care required for adequate treatment of persistent eating disorders cannot be made on the basis of weight alone, and rapid weight gain is also not a positive prognostic indicator. Per the records, this patient continued to have high levels of significant comorbidity, intrusive misperceptions, and preoccupations which presented a risk of relapse absent the intensive treatment of partial hospitalization. She continued to receive multiple psychotropic medications, including two atypical antipsychotic medications. Thus, there was an increased risk of adverse side effects from these medications. The current medical evidence supports partial hospitalization program level of care in this clinical setting. All told, partial hospitalization program services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Overturned

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for an anterior spinal instrumentation without fusion surgery. Current medical literature demonstrates the ability of spinal tethering technique for the treatment of adolescent idiopathic scoliosis to correct curves without fusion. Hoernschemeyer and colleagues report in a retrospective review of two year to five year postoperative results of 31 patients that anterior vertebral body tethering may be a reliable treatment option for adolescent scoliosis in skeletally immature individuals with higher success rates and lower revision rates. In a study of 17 patients, Newton and colleagues report that 13 of the 17 patients were able to avoid fusion with the use of anterior spinal growth tethering. The evidence shows that the requested procedure has a track record of at least five years and allows for the avoidance of standard long fusion segments in a high percentage of these cases. Therefore, anterior spinal instrumentation without fusion surgery is likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested anterior spinal instrumentation without fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Xeljanz for treatment of the enrollees rheumatoid arthritis. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested medication.  Per evidenced-based, peer-reviewed medical guidelines, Xeljanz may be recommended as a second line treatment for rheumatoid arthritis. While the records indicate this patient has tried and failed treatment with Humira, the records do not document an adequate trial and failure with Enbrel. The Health Plans requirement that the patient try Enbrel prior to treatment with Xeljanz is medically appropriate. On the basis of the available medical documentation and peer reviewed guidelines, the medication Xeljanz is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication 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 rheumatology 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 37-year-old female who is status post surgical treatment of hallux valgus deformity with chronic capsulitis of the first MPJ and severe pes plano valgus. Her provider has requested authorization for orthotics and believes without orthotics the patient will experience complications. The Health Plan has denied authorization for the requested orthotics.The information submitted provides no objective evidence demonstrating orthotics are necessary for this patient. There is no objective evidence of the patients preoperative and postoperative condition. Furthermore, there is no objective evidence demonstrating how orthotics would benefit this patients condition. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested bilateral whole breast ultrasound in conjunction with the annual mammogram for evaluation of her breast cancer screening. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. The American College of Radiology (ACR) guidelines for performance of breast ultrasound indicates that as a supplement to mammography, screening for occult cancers is recommended in certain populations of women, such as those with dense fibroglandular breasts who are also at elevated risk of breast cancer or with newly suspected breast cancer, who are not candidates for MRI or have no easy access to MRI. In addition, the Journal of the American College of Radiology recommendations, which are also made by the Society of Breast Imaging along with the American College of Radiology states that an ultrasound can be considered in high-risk women for whom magnetic resonance imaging (MRI) screening may be appropriate but who cannot have MRI for any reason or in women with dense breast tissue as an adjunct to mammography. The patient is at high risk of breast cancer, with reported heterogeneously dense breast tissue. Given the ultrasound guidelines, the requested services are medically indicated in this clinical setting. Based on the medical literature cited and the documentation submitted for review, the requested services are medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested a bilateral blepharoplasty for the treatment of his blepharitis.  Findings:  The physician reviewer found that functional eyelid surgery is indicated for any disorder that results in overt impairment of visual function or for conditions that carry the potential for injury to impairment of the eye itself (Meyer). Markedly lax or atonic eyelids may result in impairment of the lacrimal pump mechanism, resulting in epiphora (tearing). There are also various clinical situations indicating the need for lower eyelid blepharoplasty, such as secondary massive lower eyelid edema causing inability to wear spectacles, or lower eyelid malposition resulting in apposition of lashes against the cornea (Ophthalmology, 1995 Apr;102(4):693-5). From a review of the available records, it appears that the patient has symptoms of pain and irritation, with findings of lower eyelid fat herniation, blepharitis and dryness. The records clearly state that the patients symptoms are secondary to blepharitis and dry eyes rather than the lower eyelid fat herniation. Specifically, one provider states that the requested procedure would be for cosmetic purposes and none of the clinic notes suggest the patients symptoms are attributable to the lower eyelid fat herniation. For these reasons, the requested lower eyelid blepharoplasty has not been shown to be medically necessary for treatment of the patients blepharitis or dry eyes.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee has requested surgical treatment  for the treatment of his enlarged nipple. Findings:  The physician reviewer found that the records provided do not document a concern regarding malignancy or significant pain requiring analgesics. In addition, the records do not document an endocrine work-up to rule out a pathologic cause for the breast enlargement. The requested procedure is being sought primarily for emotional benefit, as the records do not provide compelling evidence of a functional problem related to the breast enlargement. Prolonged male breast enlargement can lead to pain over time, but the treatment of pain is not the primary indication for surgery at this time. Based on the ASPS guidelines, a mastectomy for gynecomastia is not established to be medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for AndroGel 20.25mg/1.25 gram (1.62%). Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting. Guidelines, such as the European Association of Urology, International Society of Sexual Medicine and Endocrine Society recommend two morning testosterone levels below reference range prior to initiation of therapy. In this patients case, there is inadequate documentation to support the diagnosis and type of hypogonadism. Moreover, the time of initial diagnosis is unknown. Recordings of two morning testosterone levels below reference range, prior to initiation of therapy, are not documented. In addition, symptoms of hypogonadism are also not documented. Most guidelines recommend treatment in carefully selected patients who have classical androgen deficiency symptoms. Lastly, documentation supporting continuous monitoring of testosterone replacement therapy is not available. Most guidelines also recommend monitoring laboratory findings (at least testosterone, hematocrit, prostate specific antigen and lipid profile) at three, six, and twelve months after initiating testosterone replacement therapy, and then annually thereafter. For these reasons, the requested coverage for AndroGel 20.25mg/1.25 gram (1.62%) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Concerta 54 mg twice per day for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), the maximum dosage for Concerta for children and adolescents is 72 mg per day. There are limited studies supporting the use of doses above 72 mg per day in adolescents. Due to the lack of peer-reviewed literature supporting Concerta with doses above 72 mg per day, Concerta 54 mg twice per day is not clinically indicated. Therefore, the request for Concerta 54 mg twice per day is not medically necessary for treatment of the patients ADHD. Final Result: The reviewer determined that the requested medication dosage 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 psychiatry with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi and ribavirin for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 2 patients, therapy is recommended with Sovaldi and Daklinza or Epclusa. This is based on the two studies for Sovaldi and Daklinza, and the ASTRAL-2 trial for Epclusa. Sovaldi and ribavirin are no longer recommended. For these reasons, although hepatitis C treatment is needed, the request for Sovaldi and ribavirin is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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 parent of an eight-year-old female enrollee has requested for a standing frame; Buffalo Stander with Head Support,  for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the standing position is vital in humans to maintain vasovagal sympathetic/parasympathetic responsiveness to prevent hypotension and to maintain varying cardiac tone for circulation. It is unlikely that this could be proven in immobile children, due to the inability to research this very limited pool. However, a study by Goemaere and colleagues found that standing in immobile paraplegics does prevent loss of bone mass. Additionally, Kunkel and Scremin have found psychological benefits of standing for bed-ridden patients.  This patient is fitted with ankle foot orthotics (AFOs) to aid in the prevention of ankle foot contractures. Gibson and colleagues noted that the use of standing frames in non-mobile children significantly improved ankle contractures.  While the feasibility of scientific studies of standing frames in this patient population is limited, it is generally accepted within the rehabilitation medical community that the standing position in immobile children will improve cardiac tone, help prevent vasovagal syncope, reduce loss of bone density, and improve pulmonary toilet. All told, the patient is an appropriate candidate for the requested Buffalo Stander with Head Support and its use in this setting is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested for a magnetic resonance angiography of the brain for evaluation of his refractory headaches. Findings:  The physician reviewer found that the published evidence-based guidelines support the use of brain imaging for some patients with headache, to address possible structural sources of secondary headache. These guidelines indicate that neuro-imaging should be considered in patients with non-acute headache and an unexplained abnormal finding on the neurological examination. The guidelines further indicate that neuro-imaging is not usually warranted for patients with migraine and normal neurological examination. Additionally, in the case of patients with atypical headache features or patients who do not fulfill the strict definition of migraine (or have some additional risk factor), a lower threshold for neuro-imaging may be applied. Imaging is also felt to be medically necessary in patients with a recent change in headache pattern, or who have other significant risk factors, such as systemic malignancy.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee requested a 12-week course of Sovaldi, Pegasys and ribavirin for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication combination.  Per the current medical evidence, the proposed treatment regimen is safe and effective for the eradication of hepatitis C virus.  The requested medication combination is likely to assist in prevention of progression of liver disease.  The current guidelines support treatment in this clinical setting.  All told, the requested 12-week course of Sovaldi, Pegasys and ribavirin is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested Genotropin for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that growth delay associated with small for gestational age, nutritional growth deficiencies, and idiopathic short stature, are all possible contributing factors to this patients condition. Assuming that he has been adequately treated by a gluten-free diet, then it is likely this patient has a diagnosis of idiopathic short stature, and is likely to be in the category of severity for which the FDA has approved the use of growth hormone (more than 2.25 standard deviations below the mean for age and sex, or the shortest 1.2% of children). All told, there is adequate evidence to justify the use of growth hormone therapy by this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested the LifeVest (automated wearable defibrillator) for treatment of the enrollees class III heart failure and non-ischemic cardiomyopathy.  Findings:  The physician reviewer found that studies assessing the efficacy of defibrillators for short periods of time during increased risk, such as after diagnosis of myocardial infarction and reduced ejection fraction of less than 35%, before ventricular function has had a chance to recover, have not demonstrated improved outcomes (Hohnloser, et al. and Steinbeck, et al.). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al.).  A prophylactic wearable external defibrillator would be indicated only if the accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. In this case, there was no urgent need for implantable defibrillator placement, as the patient remained clinically stable for approximately seven months after becoming eligible for an implantable defibrillator. Additionally, the implantable defibrillator was placed in a timely fashion, or approximately two weeks after consultation.  Therefore, the denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this clinical setting.  This patients height is more than two standard deviations below the mean for age and gender.  Her growth velocity is poor for mid-puberty.  The patient has low growth factors despite having a normal weight for height ratio, and her adult predicted height is well below the genetic target height. According to Lawson Wilkins 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 specific criteria.  This criteria includes 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 other clinical features suggestive of growth hormone deficiency.  Based upon the current medical evidence, the requested Genotropin growth hormone therapy is medically indicated for the treatment of this patient.