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

The patient is a 28-year-old male with failed back surgery and on-going chronic pain. Based upon the information provided, it appears the patient was scheduled for further back surgery in March 2005 and his provider requested authorization for Actiq for post-operative pain. The Health Plan has denied authorization for Actiq.The Health Plans denial is correct. No information has been submitted demonstrating Actiq is necessary. Although Actiq may be indicated for treatment of the patients condition in certain situations, there is no evidence suggesting this patient requires Actiq or that other indicated pain relief medications and therapies are ineffective or contraindicated for the patient. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient has not shown a significant response to ABA therapy. ABA therapy, if effective, should profoundly and permanently alter abnormal behaviors and improve social abilities. Despite extensive ABA therapy, the patient continues to present with uncontrolled self-abuse and elopement. From the medical records submitted for review, he has received ABA therapy since the age of 7. While there has been some reduction in the episodes of daily self-abuse, it was noted the patient was experiencing self-injurious behavior. In the month indicated, the patient was evaluated by a physician who noted temper tantrums occur a few times per day. Overall, the clinical findings do not demonstrate the patient has had a substantial response to ABA therapy, as there has not been significant improvement in the patients maladaptive behaviors. Based upon the submitted clinical documentation, the requested ABA therapy and supervision are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested gender reassignment chest surgery (bilateral mastectomy) for the treatment of her gender disorder of adulthood. Findings:  The physician reviewer found that the Harry Benjamin International Gender Dysphoria Associations (HBIGDA) Standards of Care for Gender Identity Disorders represent the generally accepted standard of care in this setting and are applicable in this case. This patient meets HBIGDA diagnostic criteria for gender identity disorder based on the following:the patient has a desires to live and be accepted as a member of the opposite sex accompanied by a wish to make the body congruent with this desire; the patients desire has been present for at least two years; andthe patients disorder is not a symptom of another mental disorder or chromosomal abnormality.Before beginning hormone therapy or performing breast surgery, HBIGDA criteria requires a letter from a mental health professional indicating the following:1.the patients general identifying characteristics;2.the initial and evolving gender, sexual and other psychiatric diagnoses;3.the duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent;4.eligibility criteria that have been met and the mental health professionals rationale for hormone therapy or surgery;5.the degree to which the patient has followed the HBIGDA Standards of Care to date and the likelihood of future compliance;6.whether the author of the letter is part of a gender team; and7.a statement that the sender of the letter welcomes a phone call to verify the fact that the mental health professional actually wrote the letter. Psychotherapy is not an absolute requirement for treatment and there is no specific number of required sessions before treatment. However, breast surgery produces relatively irreversible changes to the body. This is usually the first surgery performed by female to male transgender patients. For some patients (as may be the case with this patient), it is the only surgery they undertake. It is not necessary that the patient take hormones prior to this surgery. However, before performing the requested surgery, steps must be taken to ensure the patients well being. In this case, there is an absence of a letter from a mental health professional/therapist which details his or her involvement with this patient over an extended period of time and which adequately addresses all of the points mentioned above. Thus, based upon the documentation provided at this time, the medical necessity of the proposed procedure has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 10 hours per week of applied behavioral analysis (ABA) therapy, 10 hours per month of supervision and 2 hours per month of parent training for treatment of his medical condition. Findings:  Two physician reviewers found that there is sufficient support for the requested services in the peer reviewed literature in this clinical setting. According to Foxx, The only interventions that have been shown to produce comprehensive, lasting results in autism have been based on the principles of ABA. In this case, the patient has been treated with ABA services with documented progress in social skills with peers and adults. However, he requires prompting to complete his tasks. The patient has deficits related to autism that require ABA services. As recommended by the patients ABA provider, 10 hours per week of ABA therapy, 10 hours per month of supervision and 2 hours per month of parent training is medically necessary for this patients autism. Final Result: The reviewers 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: All three reviewers are board certified in child neurology 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: The parent of a 15-year-old transgender male enrollee has requested authorization and coverage for gender-affirming mastectomy. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) 7 reports that chest surgery in female-to-male patients can be performed after ample time of living in the desired gender role and after one year of testosterone treatment. WPATHs SOC 7 further noted that age does not preclude the medical necessity of chest surgery for transgender male adolescents. The WPATH SOC 7 states that chest surgery may be done in minors, and suggests, but does not require, a year of testosterone treatment. In the several years since the release of WPATH SOC 7, chest surgery in transgender male adolescents has become an effective and routine procedure. In addition, many transgender male adolescents find binding uncomfortable, and negative health effects have been reported. The providers in this case have documented the presence of persistent gender dysphoria related to the patient binding her chest. As the surgery will directly address the patients female appearing breasts, the distress related to this condition should be alleviated. All told, the requested gender-affirming mastectomy is medically necessary to treat this patients medical condition. Given these findings, the requested surgery is supported by the WPATH as medically necessary for treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested surgery is 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 with expertise in transgender health 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 pulsed radiofrequency treatments for treatment of the enrollee's complex regional pain syndrome. Findings:  Three physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the requested services. In this patients case, not all standard treatment options for complex regional pain syndrome have been tried or discussed. While research does exist for pulsed radiofrequency treatments for complex regional pain syndrome, it is of overall poor design, as thus far it is mostly case studies and retrospective analysis. Additional research is needed at this time, as clear and convincing evidence is not found in the peer-reviewed scientific journals. Based on the medical evidence, the requested pulsed radiofrequency treatments are not likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewer 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: Overturned

A 59-year-old male enrollee has requested a spinal cord stimulator for treatment of his pain. Findings:  Two physician reviewers found that spinal cord stimulation is a well-accepted modality of treatment for the management of several forms of chronic pain, including failed back surgery syndrome. Psychological evaluation is recommended, as this type of screening by a psychologist is helpful to rule out red flags such as untreated depression and other psychiatric comorbidities. None of these diagnoses were found in the patients evaluation. In this patients case, the patient would require an extensive surgery since his diagnostic discogram showed three positive discs (L1-2, L4-5 and L5-S1). The success rate of surgical fusion requiring more than two levels is low, especially if this patient may require fusion from L1 to S1.  In this patients case, the requested spinal cord stimulator is likely to be superior over other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her menorrhagia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There are many medical and surgical alternatives to hysterectomy for the management of abnormal bleeding and painful periods.  These include oral contraceptives used for non-contraceptive reasons, as well as Mirena intrauterine device.   Non-contraceptive progestins can also be used.  There is a non-hormonal treatment, tranexamic acid, which is an antifibrinolytic agent that significantly reduces heavy periods when taken orally at the time of menses.  In addition, nonsteroidal anti-inflammatory drugs can be prescribed for heavy flow and menstrual cramps.  If hormonal treatments fail to control the problem, endometrial ablation is an appropriate alternative, with less morbidity than a hysterectomy.  This patient has had an incomplete evaluation of her abnormal bleeding, with an insufficient work-up to evaluate for other etiologies for her abnormal bleeding.  Per the submitted documentation, there is no record of a complete blood count, thyroid screening, or cervical cancer screening.  Various hormonal and endometrial causes for abnormal bleeding exist, and these require blood work and endometrial sampling by biopsy or dilation and curettage to assess.  All told, the requested laparoscopic hysterectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A forty-seven year-old female with a brain tumor is requesting authorization of brain tumor surgery.Reviewers Findings:  The reviewing physician found that the requested procedure is not medically necessary.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Crohns disease of the small and large intestine with complications. The provider noted the patient has failed treatment with sulfasalazine, hydrocortisone enemas, metronidazole, thiopurines, and infliximab. The physical examination was notable for right lower quadrant abdominal tenderness. The patient reported significant fatigue and two to three formed bowel movements per day with hematochezia the prior day. The patient was being treated with Stelara 90 mg every eight weeks and methotrexate. Laboratory results dated revealed a Stelara level of 4.0 ug/mL, and there were no anti-Stelara antibodies. The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The Health Plan denied the request and reported the requested medication regimen is not medically necessary for the treatment of this patient. At issue in this case is whether Stelara 90 mg every four weeks is medically necessary for the treatment of the patients medical condition. Researchers demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate to severe Crohns disease that were resistant to anti-tumor necrosis factor (TNF) therapy. Studies performed showed a retrospective open-label study. The authors reported, The results of our study provide further evidence that subcutaneous ustekinumab treatment is associated with a sustained clinical response in the majority of anti-TNF resistant Crohns disease patients. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Stelara 90 mg every four weeks is medically necessary for the treatment of this patient. Final Result: The reviewer 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: The reviewer is board certified in internal medicine with sub-specialty 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 a 12-year-old enrollee requested inpatient psychiatric treatment for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that inpatient psychiatric services were medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed a pattern of serious maladaptive behaviors, improved for a few months, and then resurfaced a few weeks before admission. The patient had many triggers for her anger and aggression, and had no respect for authority. She became physically aggressive both at home and at school and required police to be called on three occasions. In this clinical setting, the patient must be able to cope with stress better before transitioning to a lower level of care. The patient continued to be extremely irritable and labile and over-react to seemingly minor stressors until shortly before discharge. Given her history of relapse, it was medically necessary for the patient to continue at the inpatient psychiatric level of care to ensure that she was stable before transitioning to a lower level of care. All told, the acute inpatient psychiatric services were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested partial gastrectomy and re-anastomosis of pouch for the treatment of her medical condition. Findings:  Three physician reviewers found that the size of the gastric pouch does not remain constant and is likely to stretch again with overeating.  Counseling to help modify eating habits would be beneficial here.  There is no anatomic complication of the previous surgeries. Thus, a second revision procedure is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a plastic surgeon consultation for breast augmentation.  Findings:  The physician reviewer found that The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that medically necessary gender affirming/confirming surgical procedures include chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These procedures are reconstructive surgeries. The Transgender Medicine Model NCD Working Group has explained that in transgender woman who undergo hormone therapy, maximal breast development is generally reached within two years. While hormone therapy alone is sufficient to achieve breast size appropriate to age and body habitus in some transgender women, for 40 to 70 percent of transgender women breast reconstruction may be necessary in order for the individual to pass as female and thereby reduce or resolve gender dysphoria. Mammoplasty in transgender women serves primarily a therapeutic purpose and should be considered reconstructive rather than cosmetic. In this case, the patient has been on cross gender hormone therapy and has had other gender confirming surgeries, and her gender dysphoria has not been alleviated by these other treatments. The patients therapist has confirmed that breast augmentation surgery is now required to therapeutically treat the patients gender dysphoria and relieve the patients present distress. Under these circumstances, the requested consultation with a plastic surgeon for breast augmentation is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested service is 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

A 48-year-old male enrollee requested authorization and coverage for a bunionectomy for the treatment of chronic foot pain due to sesamoiditis.  The health plan has denied this request indicating that a bunionectomy is not medically necessary for treatment of the enrollees medical condition.One podiatry reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia care (MAC) services (CPT codes 00740 and 00810) for evaluation of the enrollees colonoscopy and endoscopy. Findings:  The physician reviewer found that In regards to the use of sedation for gastrointestinal tract endoscopy, the American Gastroenterological Association Institute (AGAI) recommend that use of an anesthesia professional should be strongly considered for American Society of Anesthesiologists (ASA) physical status P3 through P5 patients. Reviewers noted that other possible indications for an anesthesia specialist include patients with pregnancy, morbid obesity, neurologic or neuromuscular disorders, a history of alcohol or substance abuse, and patients who are uncooperative or delirious. In this case, this patient presented with ASA grade II without comorbidities that would support the use of MAC services. As such, the MAC services (CPT codes 00740 and 00810) provided were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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: Overturned

The parents of a 12-year-old male enrollee requested authorization and coverage of palate expansion surgery for the treatment of cleft lip and palate.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is  medically necessary for treatment of the patients medical condition.