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

The patient had a history of gender dysphoria and has been treated with cross-gender hormone therapy since 2016. The submitted documentation indicates that patients facial hair limits her ability to be perceived and negates her gender identity. The patient reports being constantly mis-gendered due to the presence of facial hair, which exacerbates her symptoms of gender dysphoria. The documentation also indicates the patient has had both electrolysis and laser treatment in the past without side effects. A referral was made to dermatology for laser hair removal for gender dysphoria. A dermatology consultation on 11/2/18 revealed the patient was assessed for laser hair removal as part of treatment for gender dysphoria. The patient would like the facial hair treated; otherwise, she otherwise has to shave daily. This patient has a documented history of gender dysphoria treated with cross-gender hormone therapy. The patients mental health evaluation documents exacerbation of gender dysphoria symptoms due to the presence of facial hair. Guidelines for the medical necessity of facial feminization surgery (FFS) exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. On the matter of classification of laser hair removal, the WPATH states that in addition to hormonal balancing, medically necessary gender affirming/confirming surgical proceduresinclude 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. Researchers reported that on review of evidence for gender confirming surgeries, additional surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women include facial and body hair removal. The authors noted that these procedures serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Based on this patients documented history of gender dysphoria, the requested facial laser hair removal is supported as medically necessary. 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 27-year-old male enrollee has requested continued intravenous doxycycline and zithromycin for the treatment of his Lyme encephalopathy, babesia, bartonella and mycoplasma fermentans. Findings:  Three physician reviewers found that the Health Plans denial of coverage for further treatment using doxycycline and zithromax for this patient is appropriate, as the patients diagnosis/diagnoses are not clear, are not supported by the clinical notes or by the provided lab data, and the patient has not responded to many prior courses of anti-infective agents. There is no indication for such treatment at this time, as the same and similar treatments have already proven ineffective in this patient. The IDSA (Infectious Diseases Society of America) guidelines state that no scientifically valid studies have shown benefit from prolonged treatment with antibiotics for Lyme disease, and this patients course is consistent with that statement.
Appeal type: Medical Necessity
Decision: Overturned

The records provided describe a now 30-year-old female managed by her rheumatologist for fibromyalgia. It is stated that the patient has failed various agents intended to improve her sleep. Because of unacceptable daytime drowsiness, the patient has been using Provigil since 2001 with apparently good results, improving her daytime energy, though fibromyalgia continues.The records provided demonstrate the patient was earlier treated with various appropriate agents, including Flexeril, Zanaflex, and trazodone, but daytime drowsiness and fatigue continued to interfere with work and school activities. It is stated that the patient has had significant improvement in daytime energy using Provigil 200 mg daily. Provigil is employed by many rheumatologists as a standard part of the approach to the fatigue associated with fibromyalgia. Furthermore, Provigil is also often utilized for fatigue associated with depression, which is similar to fibromyalgia-associated fatigue. Therefore, given the patients history of lack of benefit with the more usual agents for fibromyalgia, and her apparent long-term benefit, the use of Provigil is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vicodin ES. Findings:  The physician reviewer found that that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The U.S. Food and Drug Administration (FDA) has approved the generic equivalents of Vicodin. In this patients case, it is reasonable to try formulary alternatives first, as there are no progress notes submitted that support the assertion that the formulary alternatives were ineffective. The medical evidence does not support the requested medication over the Health Plans alternatives in this clinical setting. All told, Vicodin ES is not medically necessary for the treatment of this patient. 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 anesthesiology with sub-specialty certification in pain 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.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female has requested coverage for past substance abuse residential treatment services for treatment of her prescription drug use.  Findings:  The physician reviewer found that the documentation provided by the treatment facility did not include a severity-of-illness and level-of-function multidimensional assessment that would justify residential level of care services during the period at issue. The patient was motivated to discontinue her benzodiazepine and some of her opiates. She was well supported by her spirituality and family. She did not demonstrate a severe mental disease or defect and did not pose an imminent threat to herself or others. There was no evidence of any previous treatment trials in less restrictive settings.  The medical documentation provided does not support the need for inpatient detoxification.  Based on the medical records provided, the patient would have been appropriate for intensive outpatient services with community support programming, such as Narcotics Anonymous during the disputed dates of service. In conclusion, the substance abuse residential treatment services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Humira (adalimumab). Currently, the peer-reviewed medical literature lacks randomized controlled trials demonstrating long-term health improvement with Humira for the treatment of folliculitis decalvans. Researchers reported on 60 patients with a minimum follow-up of five years. The authors found that of the 21 patients with folliculitis decalvans treated with clindamycin and rifampicin, 91% achieved a response, which was a greater than 75% improvement in symptoms and inflammatory signs as compared to standard therapies. This patient presents with a diagnosis of folliculitis decalvans treated with doxycycline, tetracycline, intralesional Kenalog, prednisone, and isotretinoin. Data supports the use of rifampicin with clindamycin as compared with Humira for this patient. The patients records do not include evidence that the patient has failed treatment with  rifampicin with clindamycin. For these reasons, the requested Humira (adalimumab) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Humira (adalimumab) is not 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 medication is 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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 is a 45-year-old female with approximately a three-year history of alcohol dependence, ingesting at least a bottle of wine per night, added to by daytime use of Sudafed, on the order of 10-15 tablets per day. Due to her increasing level of intake and inebriation, she decided to enter residential treatment. The patient had also experienced depression in the past, which was treated with Prozac. As of her admission, the patient was treated with a number of psychotherapies and was also begun on Lexapro.The patient has requested reimbursement for the inpatient chemical dependency services she received. The Health Plan indicates the submitted documentation does not demonstrate an inpatient level of care was medically necessary beyond the third day.Based upon review of the submitted documentation including the notes detailed above, it appears the patient was not appropriate for discharge from inpatient treatment. Notes point to the patient still being quite anxious such that, in the context of her background of chronic depression and sizable daily intake of alcohol, to have discharged her earlier would have predisposed her to relapse. The general drift of the treatments notes from the third-to last day onward, however, seem to point to a change in tenor such that discharge was appropriate. Therefore, I have determined that inpatient chemical dependency services were medically necessary for treatment of the patients medical condition through the third to last day.   Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene panel testing for evaluation of the enrollees risk for cancer. Findings:  2/3 of the physician reviewers found that There is support for the testing at issue in this patients case. The documentation noted that her mother developed breast cancer at age 53. Additionally, the patients mother reportedly tested positive for ATM mutation. The medical evidence supports the gene panel testing in this clinical setting. Thus, gene panel testing (BRCA testing and MyRisk) performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2/3 of the reviewers determined that the testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 parent of a 14-year-old male enrollee has requested for Femara 2.5mg for treatment of the enrollees short stature. Findings:  Three physician reviewers found that there is adequate evidence in the peer-reviewed medical literature to support the efficacy of aromatase inhibitors for individuals such as this patient. Femara 2.5mg 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 48-year-old female enrollee has requested for a minimally invasive laser procedure for treatment of her low back pain with right lower extremity pain.   Findings:  Three physician reviewers found that laser surgery remains experimental for the treatment of low back pain. There is not sufficient evidence in the scientific literature to show that the procedure is effective in the long-term.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a male enrollee requested Avastin for medical treatment of the enrollees malignant spindle cell sarcoma.  Findings:  Two physician reviewers found that Synovial sarcoma is a rare disease and thus, large scale clinical trials for sarcomas have small numbers of patients with synovial sarcoma. According to the current peer-reviewed medical literature, studies have demonstrated that Avastin may benefit and even halt disease progression for a period of time (Palmerini, et al; DAdamo, et al). This patient has received first-, second-, and third-line therapies for synovial sarcoma. Accordingly, the requested Avastin is supported as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested reimbursement and continued authorization and coverage for skilled nursing care services for treatment of the his medical condition.Findings:  The physician reviewer found that the patient is medically stable and does not have skilled nursing needs beyond custodial care. Functionally, the patient requires moderate to maximum assistance with bed mobility, is dependent in transfers, is dependent and requires maximum assistance of five persons in ambulation with a front-wheeled walker. The patient did not demonstrate medical or rehabilitation issues consistent with SNF level of care services.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested for DaTscan for evaluation of her history of balance problems and tremor. Findings:  Two physician reviewers found that the current medical literature has not established the superior efficacy of the requested DaTscan in this patients case.  Per De La Fuente-Fernandez, in the absence of neuropathologic validation, the overall accuracy of a clinical diagnosis of Parkinsons disease is mathematically identical to the accuracy of DaTscan imaging.  The standard of care for a diagnosis of Parkinsons disease is based on a careful taking of medical history and a thorough physical examination.  Further studies are needed to conclude that DaTscan provides health benefits, to define the clinical role of DaTscan, and to establish patient selection criteria.  Therefore, the requested DaTscan is not likely to be more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee requested authorization and coverage of transcranial magnetic stimulation (TMS). The Health Plan denied the request as not medically necessary.In its approval of TMS, the U.S. Food and Drug Administration (FDA) noted that 38 percent of patients responded to treatment with TMS with a greater than 30 percent reduction in Yale-Brown Obsessive Compulsive Scale score, whereas 11 percent of patients responded when using the sham treatment. In medical literature, Trevizol and colleagues concluded that TMS was superior to sham stimulation for the amelioration of OCD symptoms. Overall, the data shows that TMS is an effective treatment for patients with treatment resistant OCD. This patient has failed multiple psychotherapeutic agents, CBT and PHP focused on exposure and response prevention therapy for OCD. This suggests that his OCD is treatment resistant and he is a candidate for treatment with TMS. Accordingly, the requested transcranial magnetic stimulation is medically necessary for treatment of the patients behavioral health condition.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an x-ray of the lungs. This patient has a history of chronic back pain. He does not have a history of tobacco use.  The diagnostic imaging modality of a chest x-ray is indicated when there is a concern for underlying lung or heart disease. A patient may need a chest x-ray for acute complaints, such as shortness of breath, chest pain or cough. With regards to a chest x-ray in an asymptomatic patient, screening for lung cancer by chest radiograph is not recommended. In this case, the documentation does not support that the patient has symptoms that would necessitate further diagnostic work-up with a chest x-ray or has a significant history of tobacco use that would require lung cancer screening. Therefore, the requested x-ray of the lungs is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 1-year, 11-month-old male enrollee has requested individual speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition.