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

Standard Review The parent of a transgender male enrollee has requested authorization and coverage for bilateral mastectomy with bilateral nipple areolar reconstruction (CPT codes 19350.50 and 19303.50). The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment 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: The submitted documentation supports the medical necessity criteria for the requested services in this clinical setting. The surgical concept of treating breasts in individuals undergoing female to male reassignment surgery is well established and documented within the medical literature. However, each patient must be reviewed on a case by case basis to determine medical necessity. In this case, the patient has evidence of significantly abnormal breasts for a male that will not improve with continued hormonal therapy.  His photographs show evidence of grade III breast ptosis with significantly overlapping skin. He continues to experience significant gender dysphoria due to the appearance of his breasts. Therefore, the requested bilateral mastectomy with bilateral nipple areolar reconstruction is medically necessary for treatment of his medical condition.  With regard to whether the requested services are considered reconstructive in nature, reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be performed to approximate a normal appearance. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the ultimate goal. The proposed procedures are likely to create a relatively normal appearing male chest and would offer more than a minimal improvement in the appearance.  As such, the requested bilateral mastectomy with bilateral nipple areolar reconstruction (CPT codes 19350.50 and 19303.50) is reconstructive in nature for treatment of this patients gender dysphoria.  Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested for serial casting, tenotomy and follow-up care using the Ponseti Method for treatment of the enrollees club foot. Findings:  The physician reviewer found that repair of congenital club foot should be initiated as soon as possible after birth. The Ponseti Method is a non-operative procedure requiring Achilles tenotomy followed by proper gentle manipulations and plantar casts. This technique avoids surgical reconstruction correction requiring multiple soft tissue release and wire fixation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that a portion of the residential treatment center services provided were medically necessary for treatment of the patients behavioral health condition, but not thereafter. The patient had post-acute withdrawal symptoms including severe insomnia. He verbalized the desire to leave so he could use in order to sleep, placing him at imminent risk for relapse. He was depressed and anxious, but no psychotropic medications were started. He was externally motivated, but he had little insight. He participated in groups and meetings, and his Suboxone taper had completed and he was sleeping better. He was working on steps and had a temporary sponsor. As of the date of service identified, the patient could have been treated at a lower level of care. Thus, a portion of the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 56-year-old female enrollee has requested laser treatment for treatment of her sun damaged skin.  Findings:  The physician reviewer found that use of laser therapy provides cosmetic improvement in the appearance of photodamaged skin by decreasing redness and the appearance of superficial blood vessels. The effect of chronic sun exposure induces damage which in this patient has not produced any malignant or pre-malignant lesions. Further, there is no evidence that photodamaged skin exacerbates multiple sclerosis. Use of laser therapy in this patient would be considered to provide cosmetic improvement only. Thus, the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old postmenopausal woman who is presenting with long-standing back pain. Her MRI of the lower back shows mild spondylosis at L4 and L5 and L5-S1 without focal disc herniation. Her bone density shows a T-score of 1.8 in L2-4, -2.2 left femoral neck and 2.2 right femoral neck. The patient had treatment with Actonel. She is requesting coverage for Miacalcin.The patient is a 50-year-old woman with osteopenia. Osteopenia may be treated in women who are at risk of developing osteoporosis and compression fractures. Risk factors include family history of osteoporosis, history of fractures, steroid use in the past or present, significant alcohol intake and tobacco use. The submitted information does not indicate whether the patient has any of these risk factors. This patient requests Miacalcin spray for prevention of osteoporosis. The FDA allows for the use of Miacalcin in women with established osteoporosis who are five years beyond menopause. Miacalcin is not indicated for the prevention of osteoporosis. It appears that Miacalcin may reduce pain in women with severe osteoporosis and compression fractures. Review of the relevant literature reveals no clinical study investigating this issue.Miacalcin spray is not indicated for this patient. If this patient is at high risk, estrogen therapy would be medically appropriate. The patient should have her TSH level checked to be sure she is on the right amount of thyroid medications because over-supplementation may cause bone loss. The patients back pain is not related to osteopenia. Further investigation would be appropriate to rule out hyperparathyroidism. Based upon the information set forth above, 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a specific number of hours per month of applied behavior analysis (ABA) therapy, a specific number of hours of supervision and a specific number of hours of parental training sessions per month for treatment of the enrollees autism spectrum disorder. Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Per the documentation provided, the patient began attending college.  There is a lack of research regarding individuals who are able to attend college requiring or benefitting from ABA therapy.  Further, there is a lack of data regarding the use of ABA therapy to teach coping skills.  However, it is not appropriate to abruptly discontinue services in this clinical setting.  In this patients case, the requested amount of hours per month of ABA therapy, the requested amount of hours of supervision and the requested amount of hours of parent training sessions per month were appropriate initially.  However, decreasing the number of hours of ABA therapy per week was appropriate.  It is appropriate to gradually discontinue ABA therapy while starting a social skills group and individual counseling for coping skills.  Thus, a portion of the services at issue was and is medically indicated for the treatment of this patient.Final Result: Two reviewers determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing.  One reviewer is board certified in neurology with special qualifications in child neurology and is 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

A 23-year-old female enrollee has requested a Dynamic Adjustable Ankle Extension-Flexion Device (DynaSplint) for treatment of her foot pain status post surgery.  Findings:  Three physician reviewers found that there are some published case reports and case series related to the use of low-load prolonged-duration dynamic orthoses, such as the DynaSplint under review, for various joints in the medical literature (Richard, et al; Steffen and Mollinger). There are, however, no high-grade data in the published peer-reviewed medical literature supporting the efficacy of the DynaSplint for soft tissue or bony contractures at the ankle. Low-load prolonged-duration dynamic orthoses such as the DynaSplint are unsupported in the setting of contracture at the ankle following fracture. Currently, there are no high-grade data supporting the device as more effective than a rigorous active exercise and stretching program combined with appropriate analgesics and palliative modalities. Overall, the DynaSplint orthosis it is not proven to be effective for this patients medical condition. The patients ankle range of motion would have been expected to have improved following ankle capsular release and cheilectomy. There is no evidence to support that the DynaSplint therapy provided or would have been expected to provide a significant, additional functional benefit beyond the benefits expected from surgery and a rigorous active exercise and stretching program combined with appropriate analgesics and palliative modalities.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-one year-old obese female with Crohns disease and comorbidities including arthritis and hypertension is requesting authorization of a Lap-band procedure.Reviewers Findings:  The reviewing physician found that with the significant comorbidities the patient meets medical necessity criteria for weight loss surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee has requested 36 treatments of transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that to date, TMS as a therapeutic device for neuropsychiatric disorders, including depression, remains uncertain in terms of efficacy and safety. Specifically, there is limited evidence in the form of randomized clinical trials establishing the safety and efficacy of TMS for the treatment of psychiatric disorders. Most of the studies that have been published were not truly double blind and were only based on small samples over short periods of time ranging from one to two weeks. At this time, further research is needed to support the use of TMS in terms of improved health outcomes and long-term safety and efficacy when used in the treatment of depression and other psychiatric disorders. In this patients case, he has a chronic course of depression with previous treatments including many medications and prior courses of TMS. However, the current information does not support TMS as likely to provide superior health benefits compared to further conventional treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee requested radiofrequency ablation for medical treatment of her symptomatic varicose veins. Findings:  Three physician reviewers found that the current guidelines from the Society for Vascular Surgery and the American Venous Forum recommend against selective treatment of incompetent perforating veins in patients with simple varicose veins. This patients provider has planned the use of RFA ablation for the perforator vein. However, there is no history of a venous ulcer, either healed, or currently present. Therefore, the patient cannot be graded as either C5 or C6. All told, the information as presented does not support the treatment beyond conservative measures for this patients perforator vein. Thus, the requested RFA is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 15-year-old male has requested psychiatric residential treatment services for treatment of behavioral health problems.  Findings:  The physician reviewer found that given the intensity of the patients obsession with losing weight in spite of the very deleterious effects from standpoints of his health, social function, and school performance, as well as the failure of prior partial hospitalization, it was eminently reasonable to refer him to a more intensive program. Residential treatment is the only venue in which the patient can be actively prevented from continuance in the aforementioned behaviors of extreme exercise and binging and purging. Clearly, continuing along at home has done nothing to prevent those behaviors. All told, the patients admission to a residential program was medically indicated and continues to be necessary for treatment of his significant eating disorder.
Appeal type: Experimental/Investigational
Decision: Overturned

A 75-year-old female enrollee has requested speech therapy (cognitive therapy) for the treatment of the enrollee, who is status post stroke. Findings:  Three physician reviewers found that the use of speech therapy to assist with cognitive problems related to stroke is well-established and accepted. The evaluation of the patient was comprehensive and established problems with memory that were associated with communication processing. The resultant therapy, including the use of compensatory mechanisms, produced an improvement in the patients function. The submitted clinical evidence documents the gains achieved by the patient with speech therapy. She has not yet plateaued and is likely to derive further benefit from continued therapy. No other modality is likely to be more efficacious in this setting than the disputed therapy.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a skin surface biopsy Cyanoacrylate Adhesion and the following procedures by microscopy: skin scraping, adhesive bands, expressed follicular contents, comedone extraction, hair epilation, punch biopsy, and skin impression for medical treatment of her dermatitis.  Findings:  The physician reviewer found that the requested services, some of which have no relation to skin disease diagnosis or treatment are not clinically indicated. In addition, hair epilation and comedone extraction are considered dermatologic cosmetic treatments.  The patient has a number of complaints and concerns regarding infestation of the skin. It is reasonable that she see a dermatologist to rule out organic skin disease, or an infectious disease specialist to rule out systemic infection. In this case, the requested services are not medically necessary and the Health Plans recommendation to follow-up with her dermatologist is reasonable and appropriate. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old male enrollee requested intensive outpatient program for medical treatment of his alcohol dependence.  Findings:  The physician reviewer found that the the patient was having impairment across multiple functional domains due to his alcohol use, which was complicated by a formidable anxiety burden.  The submitted documentation evidenced a pattern of substance use that was unlikely to change with outpatient and community resources alone.  Despite the services at the intensive outpatient program level of care, the patient continued to struggle in maintaining sobriety.  The patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The treatment provided thereafter was reasonably expected to improve the patients condition while preventing a more serious episode of illness.  In sum, considering the relevant peer-reviewed literature and current practice guidelines, intensive outpatient program services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Lyrica 25 mg, three times per day for the treatment of the enrollees headaches. Findings:  The physician reviewer found that Lyrica is an anticonvulsant medication that is U.S. Food and Drug Administration approved for the treatment of fibromyalgia, neuropathic pain associated with diabetic peripheral neuropathy or spinal cord injury, partial-onset seizures or post-herpetic neuralgia. It is used off-label for treatment of generalized anxiety disorder, hot flashes, restless leg syndrome, and social anxiety disorder. The different subtypes of headaches include chronic migraine headache, chronic tension-type headache, medication overuse headache, hemicrania continua, and new daily persistent headache. In this case, the documentation does not provide sufficient details regarding the characteristics of the daily headache. Additionally, the submitted records do not support that the patient has exhausted pharmacologic and non-pharmacologic treatment options. The use of Lyrica is not considered first-line or second-line treatment for this patients condition. Final Result: The reviewers determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician 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: An enrollee has requested authorization and coverage for Neocate Junior formula (chocolate flavor). The Health Plan has denied this request indicating that the requested formula is not medically necessary for treatment of the enrollee who has a history of allergies to certain food.The submitted documentation supports the medical necessity for the requested oral formula. Dietary elimination is recognized as an established treatment for eosinophilic esophagitis. A four-food elimination diet with avoidance of milk, wheat, egg, and soy, can induce remission in 64% of subjects as reported in a recent publication.  However, even more stringent restrictions are not effective in all patients.  Furthermore, dietary elimination alone has not been able to maintain appropriate growth in this patient. According to the North American Society of Gastroenterology, Hepatology, and Nutritions guidelines on management of eosinophilic esophagitis, the use of elemental formula should be considered as an effective therapy in all children diagnosed with this condition. Moreover, the guidelines state that when deciding on the use of a specific dietary therapy, the patients lifestyle and family resources should be considered. This patient has also been diagnosed with autism syndrome disorder and exhibits difficulty with multiple food textures; however, the documentation indicates that she has been able to grow with use of chocolate-flavored Neocate Junior. Therefore, Neocate Junior formula (chocolate flavor) has been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested oral formula 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 pediatric gastroenterology with expertise in pediatric nutrition 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 patient is a 58-year-old male with chronic atrial fibrillation. He has been treated with Coumadin for embolic prophylaxis. He experienced a CVA at a time when his INR was sub-therapeutic. The patients treating physician has stated that control of anticoagulation has been difficult and erratic. Therefore, the patients physician has recommended a home prothrombin-monitoring device for frequent INR measurements. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. INR determinations can be performed by a lab during regular business hours. The submitted evidence demonstrates the patient is mobile and can access such services. Furthermore, the standard of care is to monitor oral anticoagulation therapy periodically rather than on a daily basis. As such, the services available from a lab are adequate. Therefore, I have determined a home prothrombin-monitoring device is not medically necessary for this patient. The Health Plans denial should be upheld.