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

Standard ReviewA transgender female enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding facial feminization surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees gender dysphoria.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. Nature of Statutory Criteria/Case Summary: There is sufficient support for the medical necessity of the requested consultation with a plastic surgeon in this clinical setting. This patient has well-documented gender dysphoria which has been treated with hormonal therapy and counseling for over one year.  She is noted to have masculine features of the face that is contributing to her gender dysphoria. The provider noted that while the patient has been on hormone therapy for almost over one year, the patients facial features are more consistent with a male appearance. It is possible there are indications for surgical treatment to establish a female appearance in this patients case.  Thus, a plastic surgeon can adequately examine and evaluate the patient to determine the appropriateness of possible surgical treatment. Therefore, consultation with a plastic surgeon regarding facial feminization surgery is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sleep study at a sleep center. The records provided for review document that this patient is at high risk for comorbidities given his obstructive sleep apnea (OSA) and possible central sleep apnea based on his history. The patient has undergone evaluation with a home sleep study, which reportedly failed to capture sufficient time to fully assess the patients condition. The patients provider has recommended further evaluation with an attended in-lab sleep study due to failing the home sleep study. In addition, the patient is noted to be taking at least one narcotic medication. The treatment of a narcotic medication coupled with the high altitude at the patients home in Utah could lead to central sleep apnea. In this clinical setting, an in-lab attended sleep study is indicated to adequately evaluate and perform continuous positive airway pressure (CPAP) titration. Medical literature noted that the American Academy of Sleep Medicine recommends use of CPAP in the routine treatment of OSA in adults. All told, the requested sleep study at a sleep center is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in sleep 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 21-year-old female has requested residential treatment for treatment of amphetamine dependence, alcohol abuse, marijuana abuse, ADD, OCD, major depression and panic disorder without agoraphobia.  Findings:  The physician reviewer found that at the time of admission to the residential faculty she was not described as being acutely ill. She was not suicidal, homicidal or psychotic.  Her illicit drug use was significant, but not causing acute medical problems. A specified criterion for admission to a residential treatment facility requires that the patient demonstrate an inability to be managed at lower levels of care. The patients past history of noncompliance with intensive outpatient treatment does not mandate that she would be noncompliant ten months later. It would have been prudent to treat the patient at a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an office/outpatient visit (CPT code 99215) and office consultation with an orthopedic medical group (CPT code 99245) for treatment of his herniated disc.  The physician reviewer found that evidence based medical peer-reviewed literature supports surgical evaluation and treatment of lumbar disc herniation as well as pain management for treatment of epidural scarring. This patient presents status post L4-5 laminectomy and repeat laminectomy with persistent low back and radicular pain with significant myelopathy. There is current imaging evidence of a new disc herniation at the L5-S1 level with annular tear extending into the neural foramen and associated moderate neuroforaminal narrowing. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial, including epidural steroid injection, medication management, and physical therapy, and failure has been submitted. Current pain management is limited to medication management. The patient has requested a second spine surgery opinion and this is supported by the treating provider. Given the significant functional weakness and age of the patient, a second spine surgery opinion based on current imaging evidence is medically appropriate and reasonable at this time. Thus, the requested office/outpatient visit (CPT code 99215) and office consultation with an orthopedic medical group (CPT code 99245) is supported as medically necessary for treatment of this patients medical 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 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: An enrollee has requested authorization and coverage for Radicava (Edaravone Injection). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees amyotrophic lateral sclerosis (ALS). At issue in this case is whether the requested medication Radicava (Edaravone Injection) is medically necessary for treatment of the enrollees medical condition.Amyotrophic lateral sclerosis is a progressive neurological disease that causes degeneration of muscles and leads to weakness with significant morbidity and mortality. The characteristics of the disease have a combination of lower motor neurological problems with upper motor neurological problems. Survival is poor with a median time of three to five years. Edaravone works on free radicals. It seeks out free radicals and it is believed to reduce oxidative stress. Oxidative stress is believed to be a mechanism in the disease process of amyotrophic lateral sclerosis. A randomized trial of 206 patients with ALS (independent living, forced vital capacity (FVC) greater than seventy percent, and disease duration of three years) by colleagues showed no benefit with edaravone versus placebo. A post hoc analysis of that trial showed efficacy of edaravone in patients with definite or probable ALS, entry scores of 2 or more on all items of the revised ALS functional rating scale, FVC of at least 80 percent of baseline, and disease duration of two years or less. A subsequent controlled trial of 137 patients designed to replicate the subset in the post hoc analysis of the trial confirmed a smaller decline in function with patient receiving Edavarone. The noted benefit reached clinical significance with slowing of about thirty-three percent in the defined population above. Regarding the use of edavarone the data for slowing of disease progression is in patients with early ALS as defined by the trials above. The patients history of ALS for longer than 2 years, several functional scores less than 2, and forced vital capacity of 54 percent does not correspond with the successful clinical trial criteria. The successful clinical trial results were in patients with forced vital capacity of at least 80 percent and disease duration of two years or less. Evidence to support efficacy and improvement in outcomes in this patient who has more advanced disease than the patient population in the successful trials is limited.  Therefore, the requested Radicava medication is not medically necessary.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 neurology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne blood test. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of lung cancer.Findings:  Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines, for non-small cell lung cancer, strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, FoundationOne blood test was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

The patient is a 44-year-old female with onychomycosis of the toenails, which has spread to all of her toenails. Based upon the information provided, treatment with Lamisil tablets resulted in an apparent drug eruption. In addition, the patient has a family history of diabetes. Because of the patients reaction/allergy to Lamisil, the patients provider prescribed Penlac lacquer for the patient. The Health Plan has denied authorization for Penlac.The fact that the patients condition has spread to all of her toenails demonstrates the patients condition is not cosmetic in nature. Because the patients resistance to this infection appears minimal at best treatment is medically necessary. Although oral Sporanox may also be helpful in treating the patients condition there is no contraindication to Penlac and Penlac is appropriate for treatment of the patients condition. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 31-year-old female enrollee has requested biofeedback and physical therapy for the treatment of her dyspareunia and severe painful muscle spasms. Findings:  Two physician reviewers found that there can be a number etiologies and contributing factors to both of these issues, and there appears to have been very little work-up by her physician. From the description of the findings by the physical therapist, there appear to be some elements of vaginismus, and a course of treatment was prescribed, including biofeedback. Biofeedback is treatment given with feedback generated to the patient to know when they are relaxing a particular muscle. The data is limited as to whether biofeedback by itself improves outcomes separate from the physical therapy. There is no evidence that this patient requires the requested services.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Ferrlecit infusions to be given every 30 days for a minimum of six months. Kaneva and colleagues report that intravenous iron is an alternative for children with severe iron deficiency anemia who have difficulty in adhering to or absorbing oral iron. The authors further note that the use of intravenous iron sucrose in pediatric patients with severe iron deficiency anemia is safe and leads to a moderate increase in hemoglobin and substantial improvement in iron studies. The records note that the patient presented to the emergency room with iron deficiency anemia leading to a syncopal episode. Laboratory testing showed a mean corpuscular volume (MCV) on the lower end at 77 fL, low iron levels of 22 mcg/dL, low iron saturation of 5%, and abnormal total iron binding capacity (TIBC) of 461 mcg/dL. The patients hemoglobin had dropped from 10.7 gm/dL to 9.4 gm/dL. In a referral form, the provider reported that the patient had very heavy and prolonged menstrual bleeding, and that she had failed oral iron supplements, which had worsened constipation and caused extreme abdominal discomfort. In this clinical setting, the administration of Ferrlecit intravenous infusions of iron is likely to be more beneficial than other forms of iron, including oral iron. Therefore, Ferrlecit infusions to be given every 30 days for a minimum of six months is likely to be more beneficial for treatment of the patients condition than any available standard therapyFindings:  Two of the three physician reviewers found the requested Ferrlecit infusions to be given every 30 days for a minimum of six months 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. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with sub-specialty certification in pediatric hematology-oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and is 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: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for aprepitant capsules. The submitted documentation does not support the medical necessity of the requested medication. Aprepitant has been approved by the U.S. Food and Drug Administration for the prevention of chemotherapy-induced nausea and vomiting. Chronic use of this medication is not recommended. In this case, the requested treatment is for aprepitant , to be used chronically for the treatment of nausea and vomiting associated with migraine headaches. The medical evidence does not support the requested medication in this clinical setting. The documentation does not support that the patient has exhausted the formulary options. There is a lack of documentation to support extenuating circumstances that would require the patient to be treated only with aprepitant. Therefore, aprepitant  capsules 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 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee requested single photon emission computed tomography (SPECT) imaging of the liver for medical evaluation of his hepatitis B and cirrhosis.  Findings:  Three physician reviewers found that SPECT is used to quantify the degree of cirrhotic changes in the liver and the physiologic congestion of the spleen as it relates to cirrhosis. The SPECT scan allows for such physiologic analysis and this evaluation is not available on standard liver scans which only allow for static imaging. The determination of the degree of cirrhosis is useful for therapeutic management including surveillance. All told, the SPECT imaging of the liver was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male enrollee has requested a new vacuum-assisted socket system leg prosthesis (L5981 and L5781) for treatment of his status post right below knee amputation.  Findings:  Three physician reviewers found that in this clinical situation, a portion of the requested device is likely to be more beneficial than other available treatment options.  Code L5981 (FlexWalk foot) is likely to be more efficacious than other treatment modalities, and code L5781 (vacuum pump suspension) is not likely to be superior over other treatment options.  A FlexWalk foot is standard equipment for a community ambulator.  In a review by Hofstad and colleagues, the authors noted functional benefits of feet such as the FlexWalk in trans-tibial amputees during decline and incline walking and increased walking speeds.  However, there is a lack of high-grade medical literature supporting the marginal efficacy of a vacuum pump assisted suspension over conventional suspension options with respect to functional or health outcomes in the setting of a trans-tibial amputation.  There are no indications in the available records that the patient has failed other appropriate conventional suspension options.  Therefore, a portion of the requested device (L5981) is likely to be more effective than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested an electron beam CT scan (EBCT) for evaluation of his chest pain.  Findings:  Three physician reviewers found that EBCT remains an unproven diagnostic modality at this time. Overall, data demonstrates that there is variable sensitivity and specificity associated with EBCT. Available studies of EBCT are limited by small sample size and have not involved clinically relevant patient populations. There are other proven modalities for chest pain evaluation such as exercise or pharmacologic nuclear SPECT imaging, which would have been more appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee requested lumbar epidural injections (CPT 62311) for medical treatment of his lumbar pain.  Findings:  The physician reviewer found that the request for lumbar epidural injections (CPT 62311) is not medically necessary.  Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in lumbosacral radiculopathy.  The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.  The peer-reviewed medical literature supports epidural steroid injections in documented cases of nerve root compression or radiculitis.  However, the patients chronic pain condition is not consistent with such a diagnosis.  In this case, the patients physical exam and lumbar spine MRI do not show evidence of lumbar radiculopathy/radiculitis.  In sum, based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a neurosurgeon for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has chronic back pain. Based on the records, she has no neurologic symptoms and no symptoms of neurogenic claudication. MRI showed no evidence of nerve root compression. The current medical evidence supports neurosurgical referral for urgent conditions such as tumor, fracture, cauda equina syndrome, and bowel-bladder incontinence. The records do not document these urgent conditions in this patients case. Based on the records, she does not have a surgical condition. The requested neurosurgical referral is not supported in this clinical setting. Final Result: The reviewer determined that the requested services 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 neurological 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.