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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for masculinization chest reconstruction procedures (CPT codes 19303  simple complete mastectomy, 19350-50 or 15200-50  nipple reconstruction). The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) states that chest surgery in female to male patients can be performed earlier than age of majority, preferably after ample time of living in the desired gender role and after one year of testosterone treatment (Coleman, et al.). Chest surgery has been demonstrated an effective treatment in transmasculine youth with gender dysphoria. Olson-Kennedy and colleagues found that chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. According to the WPATH SOC, one letter from a mental health professional meets the criteria for the requested chest reconstruction surgery. This patient has been treated with testosterone since April 2018. The patients appearance has become more masculine with testosterone, but his anxiety about his chest has become increasingly intense. The patient continues to bind his chest daily. Further, his therapist and physician support the requested surgical intervention to address the patients gender identification as male. Given these findings, the requested masculinization chest reconstruction procedures (CPT codes 19303  simple complete mastectomy, 19350-50 or 15200-50  nipple reconstruction) are medically necessary for 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for vitamin D testing (CPT code 82306), performed by Presence Healthcare Services. LeBlanc and colleagues note that vitamin D deficiency has been associated with adverse health outcomes. The clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. While the majority of patients with moderate-to-mild vitamin D deficiency are asymptomatic, severe Vitamin D deficiency results in hypocalcemia, leading to bone disorders. Rockwell and colleagues note that in the clinical management of low vitamin D, there is no clear evidence supporting vitamin D screening to improve health outcomes, and that population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of low vitamin D is not recommended. Forrest and colleagues note that patient groups with higher rates of vitamin D deficiency included those who were non-white, obese, in poor health, having low high-density lipoprotein cholesterol, and having hypertension. Others at risk for vitamin D insufficiency may include those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized patients, people with limited sun exposure, and those  with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. While vitamin D testing may be appropriate for patients at high risk for vitamin D deficiency, in this case, the submitted medical records did not note that the patient had any chronic medical conditions that would put him at risk for vitamin D deficiency. Given that vitamin D screening is not recommended for the general population, the service at issue was not medically indicated. Therefore, vitamin D testing (CPT code 82306), performed Presence Healthcare Services, was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the brand name medication, Estrace Vaginal Cream. Estrogen is the most effective treatment for patients with moderate-to-severe symptoms of vaginal atrophy. As noted in the medical literature, estrogen therapy is appropriate for patients with symptoms of vaginal atrophy in the setting of low estrogen levels, provided there are no contraindications to this therapy. Adequate estrogen therapy can lead to restoration of a patients normal vaginal acidic pH and microflora, thickening of the epithelium, increased vaginal secretions and decreased vaginal dryness. The formulations available for vaginal estrogen therapy include conjugated estrogens (cream) and estradiol (cream, tablet, and ring). In a study reported by Lethaby and colleagues, the authors conducted a systematic review of 19 randomized trials included over 4,000 patients treated with local estrogen treatment. The authors found that creams, tablets, and rings were all similarly effective in relieving symptoms of vaginal atrophy. In this case, the patient has been maintained on brand name Estrace vaginal cream for many years with good response. An attempt at using generic estradiol resulted in an immediate adverse reaction. Thus, continuation of the brand name medication Estrace vaginal cream is appropriate for this patient. Therefore, the brand name medication, Estrace Vaginal Cream, is medically necessary to treat the 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for laser hair removal. The enrollee has a recurrent pilonidal cyst. He underwent cyst excision. The enrollee reports the cyst did not cause problems for a year after laser hair removal, but then it recurred. The enrollee is status post pilonidal Gips procedure. He reports pain with sitting. The surgeons recommendation was for a new referral for repeat laser hair removal. Literature does not support the requested laser hair removal is medically necessary to treat the enrollees condition, as there are other depilatory methods to remove hair. The literature is not definitive in its recommendation regarding laser hair depilation for the treatment of pilonidal cyst disease. Further randomized trials are needed to clarify the role of newer techniques for treating pilonidal disease. A literature review showed a lower recurrence rate after laser hair removal, but the sample size was small and the studies were of limited methodological quality. A separate literature review on laser hair depilation in pilonidal disease and its effect on disease recurrence showed the literature published to date is of small sample size and has limited generalizability.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested three level disc replacement (insertion of more than one (three) artificial intervertebral discs) for treatment of his medical condition.  Three physician reviewers found that in this patients case, the services at issue were not likely to have been superior over other treatment options.  Hacker and colleagues noted that despite their similarities, cervical arthroplasty and fusion were not equivalent procedures in regard to very late complications.  The authors noted that delayed device related complications may occur with cervical arthroplasties, and these complications commenced beyond the time frame for complications associated with traditional cervical spine procedures.  Although the records noted the patient continued to have complaints of upper extremity pain and subjective complaints of radicular symptoms as well as decreased muscle strength, the clinical information submitted did not provide documentation of hyperreflexia or pathologic reflex deficits.  The sensory examination was noted to be intact as well.  Per the medical literature, further studies are needed to determine the long-term efficacy of the services at issue.  All told, the superior efficacy of the three level disc replacement has not been established. Final Result: Three reviewers determined that the services at issue were 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:  All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of patent foramen ovale (PFO) and left atrial appendage for treatment of her cerebrovascular accident (CVA) and PFO. Findings:  Two physician reviewers found that based on review of the recent literature, there is a paucity of data demonstrating a benefit of PFO closure over medical therapy. Li and colleagues found that the combined data from randomized controlled trials have shown no statistically significant differences between transcatheter device closure of a PFO and medical therapy in the prevention of ischemic stroke after a cryptogenic stroke in the setting of a PFO. In addition, the RESPECT trial in the intention-to-treat analysis did not report a benefit of transcatheter closure over medical therapy in the treatment of PFO. Given the lack of strong statistical support for a benefit of transcatheter PFO closure over medical therapy, the requested transcatheter closure of PFO and left atrial appendage are 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 procedures 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found there is sufficient support for the services at issue in this patients case. The records indicate that the patient will fit the criteria for advanced maternal age at the time of delivery. Current recommendations include cell-free DNA testing as a viable option for all women after evaluation and counseling. Therefore, genetic testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter placement of intravascular stent for treatment of the enrollees bilateral carotid disease. Findings:  Two physician reviewers found that There is sufficient support for the requested services in this clinical setting.  The patient has coronary disease, hypertension, hyperlipidemia and severe, symptomatic carotid stenosis. Per the current guidelines, for symptomatic, high risk patients with severe carotid stenosis, carotid stenting is considered a class IIA indication, with the weight of evidence in favor of treatment.  Carotid stenting is reasonable as it is a less invasive, safer alternative to surgery for this patient. Thus, the requested transcatheter placement of intravascular stent is likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the requested services are 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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Zyprexa for treatment of his behavioral health condition.  The physician reviewer found that Zyprexa is not medically necessary for treatment of the patients medical condition. Zyprexa is a second generation, or atypical, antipsychotic medication that is approved by the U.S. Food and Drug Administration (FDA). One of its several indications is the treatment of schizophrenia. However, one factor that distinguishes the second generation class from the typical neuroleptics is the risk of metabolic syndrome, which is characterized by obesity, impaired glucose metabolism and dyslipidemia. Confounding this potential safety complication is that diabetes is up to four times more frequent in patients with schizophrenia compared to the general population. This relationship led to a collaborative effort between the American Psychiatric Association, the American Diabetes Association, the North American Association for the study of Obesity and American Association of Clinical Endocrinologists, the outcome of which was the development of consensus guidelines on monitoring and description of the differential risk of metabolic effects for the atypical antipsychotics. Zyprexa was described as having the greatest effect on weight and risk for diabetes. This association was illustrated again in the National Institute of Mental Health sponsored Clinical Antipsychotic Trials of Intervention Effectiveness study which noted that patients receiving Zyprexa demonstrated a greater than 7% weight gain from baseline in 30% of patients. With the experience of clinical practice and the guidance from national professional organizations, metabolic monitoring is now standard clinical practice during antipsychotic pharmacotherapy. As such, the requested medication cannot be considered safe for maintenance therapy, and thus is not medically necessary. Based on the documentation provided, Zyprexa is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 skilled nursing facility (SNF) services including physical rehabilitation for treatment of the her stage IV breast cancer. Findings:  The physician reviewer found that in the documentation available for review, this case illustrated the importance for clear communication and involvement of palliative and hospice care services as soon as possible. It is well known in the literature that physical and occupational rehabilitation therapy with patients in end stage cancer care is helpful with their overall condition as well as their quality of life. In this case, continued rehabilitation is indicated and appropriate. However, the need for those rehabilitation efforts to be performed at a SNF is not supported as medically necessary. The patients spouse acknowledged the difficulty of rehabilitation efforts while the patient was at the SNF. Thus, home hospice rehabilitation therapy should be continued. In addition, being allowed to pass in the familiar setting of ones own home does bring the greatest satisfaction both to the one dying and to the loved ones by their side. 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 anesthesiology with sub-specialty certifications in pain medicine and hospice and palliative care and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 5-year-old male enrollee requested authorization and coverage of sensory integration therapy for the treatment of autism.  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 upheld the health plans denial on the basis that 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: The American Society of Interventional Pain Physicians (ASIPP) guidelines on opioids for chronic non-cancer pain recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses, within FDA recommended doses. In addition, researchers performed a review of the evidence supporting methadone for chronic non-cancer pain in adults. The researchers concluded that there is limited evidence of the efficacy of methadone for chronic non-cancer pain and no conclusions can be made regarding differences in efficacy or safety between methadone and placebo, other opioids, or other treatments. In this case, the patient has been treated with hydrocodone and oxycodone for breakthrough pain. However, there is no documentation that he has tried and failed other long acting pain medications as recommended by the ASIPP guidelines. Based on these findings, the requested methadone 10 mg is not medically necessary for management of this patients chronic pain.Final Result: The reviewer determined that the requested methadone 10 mg 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 subspecialty certification in pain management 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

A 20-year-old female enrollee has requested the use of a real time remote heart monitor (electrocardiographic monitor) for an evaluation of her heart condition. Findings:  Two physician reviewers found that this patient clearly had symptoms that could not be confined to a 24-hour period and other options, such as obtaining an electrocardiogram during the episode, were not practicable. The only means to establish the presence of an arrhythmia was by the use of the real-time remote heart monitor (electrocardiographic monitor) during the symptoms. There is every clinical indication to use an event recorder such as this which can be triggered by the patient during her episodes. This would, undoubtedly, help, not hinder in looking after this patient. Thus, the use of a real-time remote heart monitor was appropriate and indicated.