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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. Findings:  The physician reviewer found that Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. She has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the best extent possible. Additionally, facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature. 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 dermatology 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 gene testing performed for evaluation of the enrollee, who was diagnosed with indeterminate follicular neoplasm. Findings:  Three physician reviewers found that a fine needle aspiration (FNA) biopsy yielded cytology which was suggestive of a follicular neoplasm (Bethesda Category IV). A specimen was subsequently sent for gene testing rendered. While a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign.  The Afirma thyroid FNA analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries.  This test is very sensitive and has a high negative predictive value. A negative Afirma result is suggestive of a benign nodule and can therefore preclude surgical procedures. Final Result: Three reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for digital breast tomosynthesis for a breast screening mammogram. Findings:  2/3 of the physician reviewers found that the patient is a 50-year-old female who was asymptomatic with respect to her breasts.  The patient had screening mammogram including digital breast tomosynthesis followed by whole breast ultrasound. There was no evidence of cancer. The Health Plan has denied the digital breast tomosynthesis portion of the examinations as investigational. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies. Moreover, the studies have shown an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists when interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective for the patient than had her examination been performed using two dimensional imaging alone. Final Result: 2/3 of the reviewers determined that  the service at issue was 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 reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 14-year-old female enrollee requested tooth extraction(s) to occur in a hospital setting with monitored anesthesia care (MAC) for medical treatment of the enrollees tooth extraction.  Findings:  The physician reviewer found that the patient is symptomatic with a history of POTS. The neurology consultation resulted in a recommendation to perform the procedure in a hospital setting.  Although it is not always possible to predict how an individual patient will respond during a planned procedure, in this case the patient has a known diagnosis of POTS, which makes her more susceptible to syncope and autonomic dysfunction, which can arise after an event that causes stress, such as a tooth extraction. Based on the consideration of the patient specific factors and the recommendation from pediatric neurologist, the requested tooth extraction to occur in a hospital setting with MAC is medically necessary. Therefore, the medical necessity of the requested services has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female with rheumatoid arthritis. The patients treatment regimen includes Remicade, Arava, prednisone, ibuprofen, and Excedrin. The patient has apparently had severe pain related to her rheumatoid arthritis and secondary degenerative joint disease, and recently underwent a hip replacement. The patients provider states the patient was given Actiq for breakthrough pain in association with her osteoarthritis prior to her hip replacement.The materials provided demonstrate the patient received an extensive array of narcotic medications in June, July and August 2004, including, oxycodone, OxyContin, Endocet and Kadian. Records from 8/31/04 indicate the patient was in no acute distress though she continued to take OxyContin 80mg three times daily. Included in the patients providers assessment were total body pain and chronic opioid therapy. A request has been made for reimbursement for Actiq. The Health Plan has denied this request on the basis that Actiq was not medically indicated for treatment of the patients medical condition. Based upon the information provided, it appears the patient has rheumatoid arthritis, secondary degenerative joint disease, and a chronic pain syndrome. Her pain syndrome has led to treatment with extensive narcotic medications, which does not address the cause of her pain. Prior to her hip replacement, Actiq was prescribed without indication, in what was apparently an escalating regimen of narcotics. The records note that after the hip replacement the patient continued to require OxyContin for pain control, though the ongoing cause of pain is not clearly described and it is known if she continued to receive other medications as well. Actiq is a short-acting nasally-administered narcotic with clearly limited indications (i.e., breakthrough pain in cancer patients). It is not intended for use in other pain syndromes. This patient was prescribed Actiq without appropriate indications. Therefore, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hip and knee replacement. Findings:  The physician reviewer found that records document that this patient is being treated for right hip arthritis and bilateral knee arthritis. The patient reports hip and knee pain with walking and standing. The patient endorses use of a walker or cane for ambulation. The patients physical examination revealed right hip crepitus, decreased range of motion and right knee tenderness, as well as an antalgic gait. The patients records also state that recently she presented with alcohol intoxication and subsequent withdrawal, which required a hospital admission. The treating provider charted that the patient should be sober for six months prior to undergoing arthroplasty surgery. The records do not suggest that the patient has participated in a recent physical therapy program or undergone cortisone injections since February 2022. The medical literature and guidelines recommend adequate treatment with conservative modalities prior to consideration for arthroplasty procedures. Riddle and colleagues reported that the risk-to-benefit ratio for total knee arthroplasty favors patients who have intense or severe symptoms of knee osteoarthritis, are at least 55-years-old, have limited mobility, and have a body mass index (BMI) less than 40 kg/m2. Van Zaanen and colleagues noted that the guidelines for managing hip and knee osteoarthritis advise extensive non-surgical treatment prior to surgery. The authors evaluated hip and knee osteoarthritis patients who received non-surgical treatment prior to arthroplasty and assessed patient satisfaction regarding alleviation of symptoms and performance of activities. The authors concluded that hip and knee osteoarthritis patients were mostly satisfied with non-steroidal anti-inflammatory drugs (NSAIDs) followed by exercise-based therapy. Overall, there is a paucity of large-scale prospective studies showing the long-term safety and efficacy of hip or knee arthroplasty in this patients clinical setting. For these reasons, the requested knee replacement surgery and hip replacement surgery are not medically necessary for treatment of this patient. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a cardiac computed tomography (CT) scan (coronary calcium without contrast). Findings:  Two of three physician reviewers found that this patient presented with increased coronary risk but no documented chest pain, cardiovascular physical examination abnormalities or electrocardiographic changes. In this circumstance, current guidelines on the evaluation and management of cardiac risk do not recommend routine performance of coronary CT scanning to help guide further management. Treatment change based on CT results has not been shown to incrementally improve outcome when compared to outcomes from treatment based on clinical risk and standard lipid analysis alone. In sum, CT scan (coronary calcium without contrast) is not likely to be of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) level of care. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had significant risk of harm, due to recent use of alcohol and marijuana prior to IOP admission, and self-harm and disordered eating even after months of IOP treatment. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment, due to disordered eating, interpersonal conflict with parents, and struggles with interpersonal connections and relationships. The patients sobriety while enrolled in IOP demonstrated gains and/or stabilization in functioning while participating in a structured, protected, and/or enriched service.With regard to comorbidity, the records support a score of 3. The patient had significant co-morbidity, due to the presence of substance abuse, disordered eating, depressed mood, and anxiety. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a stressful environment due to role expectations that exceeded the patients given age, status, and developmental level, as demonstrated by patients feeling overwhelmed by academic expectations. With regard to level of support of the recovery environment, the records support a score of 2 due to parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient had significant resiliency and/or response to treatment but required formal supports or ongoing care in alternative supportive relationships, as demonstrated by the patients ability to maintain sobriety within the structure and support of the IOP program. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated somewhat passively in treatment. Thus, the patient has a total score of 18. In this case, the recommended level of care is high-intensity community-based services. This is consistent with the IOP level of care the patient received. Therefore, IOP level of care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

The patient has requested authorization and coverage for Zolinza 100 mg. The records provided for review document that this patients treatment regimen has included multiple standard therapies for high-risk neuroblastoma, including temozolomide and irinotecan, radiation, and dinutuximab. The patient is noted to maintain a strong performance status. The patients provider has recommended Zolinza as part of his treatment regimen to be taken with Accutane. Zolinza is a histone deacetylase inhibitor used in the treatment of cutaneous T-cell lymphoma. Additional data from medical literature reports that when combined with retinoids, Zolinza produces additive antitumor effects in preclinical studies of neuroblastoma. Similarly, researchers found that studies suggest that histone deacetylase inhibitors restore tumor sensitivity to retinoids and have synergistic anti-tumor activity when combined. Given this support in the peer-reviewed medical literature, the requested Zolinza 100 mg is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication 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 subspecialty certifications in medical oncology and hematology 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

A female enrollee requested the zoster vaccine for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services. Per the current medical evidence, the use of the zoster vaccine is recommended in people age 50 to 59 due to proven efficacy of the vaccine in this age group.  As noted by Schmader and colleagues, zoster vaccine efficacy for preventing infection was 69.8% in this group.  Zoster vaccine reduced the incidence of herpes zoster.  All told, the zoster vaccine was medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested gemcitabine (Gemzar) and Taxotere (docetaxel) chemotherapy for the treatment of her leiomyosarcoma. Findings:  The physician reviewer found that there is no convincing data to support the benefit of adjuvant chemotherapy in stage I uterine sarcoma. At this time, such therapy must be considered unproven, and therefore, not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old female with a history of depression, gastroesophageal reflux disease, post-polio syndrome, and excessive daytime sleepiness. No evidence of narcolepsy or obstructive sleep apnea has been provided. The patient is being managed with Provigil 200mg as recommended by her pulmonologist. The patients documented weight is 229 pounds. The submitted medical records do not include documentation of polysomnography or multi-sleep latency testing to determine if the patient has hypersomnolence due to narcolepsy or obstructive sleep apnea. The patient reports her fatigue has improved with Provigil. The Health Plan has denied authorization for Provigil on the basis that it is not medically necessary for treatment of the patients medical condition.Provigil has generated a wide variety of clinical and prospective trials for fatigue-associated illnesses. Though the patient reports that Provigil has improved her fatigue, Provigil has not been approved for treatment of post-polio syndrome. Provigil is indicated for treatment of narcolepsy and obstructive sleep apnea. The submitted information does not include documentation of polysomnography or multi-sleep latency testing to determine if the patients hypersomnolence is due to narcolepsy or obstructive sleep apnea. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, the patient should undergo polysomnography and multi-sleep latency testing in order to determine if she has narcolepsy or obstructive sleep apnea. If the results of the sleep studies are consistent with narcolepsy or obstructive sleep apnea, the patients request for Provigil should be reconsidered.