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

Nature of Statutory Criteria/Case Summary: An enrollee has requested rhinoplasty and lip filler injections for treatment of her gender dysphoria. The physician reviewer found that per the World Professional Association for Transgender Health (WPATH) Standards of Care regarding the medical necessity of sexual reassignment surgery (SRS) including facial feminization surgery, `Professionals who provide services to patients with gender conditions understand the necessity of SRS, and concur that it is reconstructive, and as such should be reimbursed, as would any other medically necessary treatment.` In this patients case, multiple practitioner notes clearly document the patients diagnosis of gender dysphoria. The Health Plan has approved frontal bone contouring with hairline lowering and laryngochondroplasty, thus establishing that a component of this patients gender dysphoria is related to the masculine appearance of her face. All told, the requested rhinoplasty is medically necessary to treat the patients gender dysphoria. This procedure is also considered reconstructive in nature in that the patients nose contributes to the masculine appearance of her face and therefore in the context of her being a transgender woman, the nose has developed abnormally for a genetically born female. Further, the proposed rhinoplasty should improve the patients appearance to a softer, more feminine appearance and is likely to result in more than a minimal improvement in her appearance. With regard to the requested lip filler injections, lip augmentation is not considered to be a standard treatment for gender dysphoria. Thin lips, or lips that would benefit from a more full appearance, can occur in any female and are not considered a marker for a masculine appearance. As such, the proposed lip filler injections are not medically necessary or considered reconstructive in this case. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Specifically, the requested rhinoplasty is medically necessary and reconstructive in nature. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone HCl tablets for treatment of the enrollees pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. There is no clear indication for the use of chronic opiate therapy in this patients case. There is no documentation of a current opiate maintenance agreement, urine toxicology testing or description of therapeutic goals. There is no formal risk assessment other than a statement that her Arizona prescription monitoring program showed no problems. The Centers for Disease Control and Prevention clinical practice guidelines for prescribing opiates do not support the requested medication in this clinical setting. A study noted that there is little evidence to support long-term opiate therapy for low back pain. The current medical evidence does not support the requested medication in this patients case. All told, the requested oxycodone HCl tablets are 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose.Findings: Two of the three physician reviewers found the requested Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The current medical literature supporting the use for secukinumab for the treatment of hidradenitis suppurativa is limited to case reports of a few open label and retrospective studies without randomization or a control group. Of note, researchers report that there are cases of secukinumab inducing hidradenitis suppurativa. In a retrospective study of 31 patients with hidradenitis suppurativa treated with secukinumab, researchers concluded that the effectiveness of secukinumab in the treatment of moderate-to-severe hidradenitis suppurativa was not entirely confirmed. Researchers do not include secukinumab in clinical management guidelines for hidradenitis suppurativa. Rather, the authors recommend approaches including but not limited to ertapenem, cyclosporine and oral retinoids. Therefore, Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose, are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication regimen 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 parent of a three-year-old male enrollee has requested an intensive feeding program therapy for treatment of the enrollees oral dysphagia and pervasive developmental disorder. Findings:  The physician reviewer found that this patient is dependent upon nasogastric feedings due to medical and developmental problems and is only able to tolerate small amounts orally, an intensive inpatient feeding program is a reasonable approach. He relies on nasogastric feedings for the majority of his nutrition. He has received standard outpatient feeding therapy since infancy but he has not made enough gains with these interventions to relieve him from the need for nasogastric feedings. The medical literature supports the utility of specialized inpatient treatment programs for children whose feeding problems are refractory to standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-month-old female enrollee has requested for chiropractic services for treatment of the enrollees torticollis and plagiocephaly. Findings:  The physician reviewer found that studies suggest that chiropractic intervention is a viable treatment option for congenital muscular torticollis. According to the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Guidelines), chiropractic care for the treatment of torticollis is acceptable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested for a PET scan for evaluation of his splenic lesions. Findings:  The physician reviewer found that positron emission tomography (PET) scans are a noninvasive imaging method to assess the level of metabolic activity and perfusion in various organ systems of the body. PET scans have proven clinical utility in the evaluation and management of several cancers. However, the current clinical scenario does not meet the Medicare criteria or the Health Plans criteria for coverage of a PET scan since the patient does not have a histological diagnosis of cancer. The other scenarios for which PET scan is covered for oncologic screening, such as a solitary pulmonary nodule, are not present in this case. The utility of PET scans in differentiating non-cancer etiologies such as infection, inflammation or rheumatologic/autoimmune conditions from malignancy in patients with multi-system involvement has not been well characterized.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old male who underwent excision of a right calcaneal spur in April 2005. Left heel spur surgery was performed several years ago. After wearing the same pair of orthotics for over 10 years, the patients podiatrist recommended a new pair of custom orthotics. The Health Plan has denied authorization for the requested orthotics on the basis they are not medically necessary.There has long been a debate regarding the efficacy of pre-fabricated orthotics versus custom orthotics. Recent literature concludes that pre-fabricated orthotics are equally effective as custom orthotics. There is no evidence that the patient will not benefit from pre-fabricated orthotics. Although pre-fabricated orthotics may lose their efficacy sooner than custom orthotics, they can be replaced as needed. Therefore, I have determined the requested orthotics are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-seven year-old male with prostate cancer is requesting authorization and coverage of proton beam radiation therapy.Reviewers Findings:  The reviewing physician found that the requested services are not medically necessary for treatment of the patients medical condition.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for a pelvic CT scan for evaluation of her ovarian mass.   Findings:  The physician reviewer found that pelvic CT was not medically to assess the patients condition as ultrasound is generally superior in assessing adnexal structures and it had already been performed.  It is unclear what additional information could have been obtained from pelvic CT.  In addition, it is unclear how the results of the CT scan would have impacted the patients treatment plan based upon the results of the ultrasound. As such, there is no evidence establishing the medical necessity of the pelvic CT scan.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested dental treatment for the build-up to tooth, post root canal for orthodontic needs. Findings: The physician reviewer found that the Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees tooth fracture.  The records document that the patient sustained dentoalveolar trauma. On follow-up with his provider, tooth number 9 was found to be necrotic and required endodontic treatment and build-up. In addition, tooth number 9 was malpositioned and orthodontic treatment was appropriate to restore it to its correct position. Thus, the treatment provided was within standard accepted guidelines. Orthodontic treatment to reposition the involved tooth into an ideal position was indicated and is a known sequela after such trauma. All told, the build-up to tooth, post root canal for orthodontic needs provided to this patient following the dentoalveolar trauma was medically necessary.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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sodium hyaluronate/hyaluronan injection series (either a series of four Orthovisc injections or a series of three Gelsyn-3 injections) in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this patients case, there is a history of lasting benefit from viscosupplementation of both knees. The injections helped to reduce his knee pain. Oral and topical medications were not effective. Therefore, the requested sodium hyaluronate/hyaluronan injection series (either a series of four Orthovisc injections or a series of three Gelsyn-3 injections) in both knees is 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for diastasis recti repair surgery. At issue is whether the diastasis recti repair surgery was medically necessary for treatment of the patients medical condition. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Current peer-reviewed medical literature has not established that abdominal rectus diastasis repair provides long-term relief of symptoms and improvement of function. Researchers suggested that surgical correction of abdominal rectus diastasis could improve functional ability and quality of life. However, the researchers did not report on any studies demonstrating that abdominal rectus diastasis repair provides long-term relief of symptoms, improvement in function, or increased abdominal wall muscle strength. Medical literature noted that the clinical significance of abdominal rectus diastasis remains inconclusive. Based on current literature and the medical information received for review, the diastasis recti repair surgery was not medically necessary.Applying the California Reconstructive Surgery Statute, reconstructive surgeries are defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: to improve function; or to create a normal appearance, to the extent possible. There is a lack of documentation that abdominal diastasis rectus repair corrects or materially improves a bodily function. The documentation does not suggest that the provider recommended the procedure to improve the patients function. Moreover, the preoperative photographs reviewed demonstrate a female abdomen that is not abnormal, but within the wide range of normal. Thus, diastasis recti repair would not have made a more than minimal improvement in the appearance of the patient. Therefore, the diastasis recti repair surgery was not medically necessary and not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical conditio
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine at a quantity of five per day. The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The current medical evidence does not support chronic opiate use for the treatment of fibromyalgia and radial nerve neuropathy. Chronic opiate use for non-malignant pain is not recommended by the Centers of Disease Control and Prevention and has many side effects, including opioid-induced hyperalgesia. Therefore, morphine at a quantity of five per day is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for the durable medical equipment device, Eneura Transcranial Magnetic Stimulation. Findings: Two of the three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested device. There are several tools used in the treatment of migraine. These tools include Botox, oral medications, and pain relieving devices. One of those devices is the Eneura device. The ESPOUSE trial demonstrated some benefit for migraine therapy. Despite positive results, the Eneura device has not been compared to other available standard therapies. While the patient has tried several migraines therapies, the records do not document that the patient has exhausted standard available options. Therefore, the requested durable medical equipment device, Eneura Transcranial Magnetic Stimulation, is not likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device 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 neurology 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: Experimental/Investigational
Decision: Upheld

A male enrollee requested PCA3 testing, (CPT 84999) for medical evaluation of his prostate cancer.  Findings:  Two physician reviewers found that the medical literature indicates that PCA3 testing, (CPT 84999) most useful role is in the context of a negative prostate biopsy, and where a confirmatory repeat biopsy would generally be recommended. Based on the documentation submitted for review, this patient has a confirmed diagnosis of prostate cancer and there is a lack of documentation demonstrating the clinical indication for the PCA3 testing and the information it would provide. In addition, the National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer do not recommend use of PCA3 testing. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xeljanz for treatment of the enrollees alopecia universalis.  Findings: Two physician reviewers found that Alopecia areata (AA) is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of AA including eyebrows, eyelashes and facial hair. Treatment is challenging and aims at the regrowth of hair. AA causes dramatic and devastating emotions in patients, which can negatively impact their self-esteem, body image, and/or self-confidence. The experience of alopecia is psychologically harmful and can result in emotional distress. Xeljanz (tofacitinib) is an oral JAK inhibitor approved for the treatment of moderate to severe rheumatoid arthritis. Xeljanz has also been studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the medical literature demonstrate the effectiveness of tofacitinib in the treatment of AA (Jabbari, et al; Gupta, et al). Given the support in the peer-reviewed literature, Xeljanz is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested medication 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.Credentials/Qualifications: All three physician reviewers 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.