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

A 20-year-old female enrollee has requested left lower eyelid blepharoplasty for treatment of her dermatochalasis.  Findings:  The physician reviewer found that the medical literature consistent describes lower blepharoplasty as a cosmetic procedure. In this patients case, the requested blepharoplasty is not going to resolve any functional problems although it will provide a cosmetic improvement. The patients symptoms of tearing and eye redness may require alternative medical or surgical therapies. However, blepharoplasty is not indicated for either of these symptoms. All told, the requested surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coronary computed tomography angiography (CCTA) for evaluation of the enrollee, who has aortic valve stenosis.Findings:  The two of the physician reviewers found that This patient had increased coronary risk and severe asymptomatic aortic valve stenosis with normal left ventricular systolic function. In this circumstance of no documented cardiac symptoms and normal left ventricular function, there is no accepted indication for aortic valve replacement according to current guidelines endorsed by several national organizations. Therefore, coronary angiography was not indicated. Moreover, if coronary angiography were thought to be indicated, then conventional coronary angiography would be preferred, given its improved accuracy relative to CCTA and the ability to intervene with coronary revascularization during the same procedure, if clinically indicated. In sum, CCTA was not 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 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 reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 internal medicine with sub-specialty certification in cardiovascular disease 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 internal medicine with sub-specialty certification in cardiovascular disease 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 Xeljanz XR tablets. Findings: Guidelines for the treatment of rheumatoid arthritis recommend that if disease activity remains moderate to high despite therapy with DMARDs, then tumornecrosis factor inhibitor (TNFi), non-TNF biologic, or tofacitinib may be added to DMARD therapy. The guidelines do not specify an order in choosing the next drug to be added to traditional DMARDs. A study found that tofacitinib monotherapy was associated with reductions in signs and symptoms of rheumatoid arthritis as well as improvement in physical function. In this case, the patient continued to have uncontrolled rheumatoid arthritis disease activity despite DMARD monotherapy, and had failed anti-TNF therapy. The provider added Xeljanz to optimize disease control. The records show that the patient achieved improved disease control using Xeljanz. Given the medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xeljanz XR tablets are medically necessary for the 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 sub-specialty certification in rheumatology 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

This patient is a five-year-old male with a diagnosis of autism accompanied by receptive and expressive language delays.  He received speech therapy and auditory processing therapy from April 2005 through November 2005. The patients parent has requested reimbursement for the cost of the auditory processing therapy.  The Health Plan denied the request based on a determination that the therapy was not medically necessary for treatment of the patients receptive and expressive language delays.I have reviewed the available literature including a Cochrane review of auditory integration training (AIT). There is no evidence of functional benefit with AIT and the available data does not support the application of the therapy. Additionally, any suggestion of an improvement in language skills related to the auditory processing therapy is questionable as the patient was receiving concomitant speech therapy, which could be the sole basis for his gains. Therefore, I have determined the therapy 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

The patient is a 58-year-old female three years post gastric bypass with weight loss in excess of 160 pounds. She has experienced anatomic changes due to massive weight loss. The patient indicates she is troubled with the laxity of her upper arms. Accompanying photographic evidence documents hanging excess skin of the arms. A request has been made for surgical excision of the excess skin. The Health Plan has denied the request on the basis that the requested procedure is cosmetic in nature and not medically necessary.The submitted photographic evidence of the patients hanging skin of the upper arms does not demonstrate medical necessity for the requested procedure. Evidence of a functional impairment has not been provided. Thus, there is no indication that the requested procedure is medically warranted in order to treat clinical symptoms or functional complaints. Therefore, I have determined that the requested procedure is cosmetic in nature and not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay performed.  Findings:  The physician reviewer found that the DecisionDx melanoma assay tests the tissue genetics of an individual patients melanoma and can stratify whether a thin melanoma is high risk for metastasis. The DecisionDx has shown some impressive accuracy in melanomas like this patients tumor. However, there is a lack of data supporting treatment decision making based on the results of the test. Overall, there is a paucity of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. Further, the test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Given these findings, the DecisionDx melanoma assay performed on was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was 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 & 3  are  board certified in dermatology 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

The parent of a 21-month-old male enrollee has requested repair of the transverse arch and tricuspid valvuloplasty for treatment of the enrollee's medical condition.   Findings:  The physician reviewer found that  the submitted documentation supports the medical necessity of the requested services in this patients case.  In order to have a successful Fontan operation, the patient must have good right ventricular function, a competent tricuspid valve and unobstructed flow through the lungs.  This patient is not a Fontan candidate at this time due to severe tricuspid regurgitation and what appears to be significant long segment left pulmonary stenosis due to the enlarged transverse aorta.  However, his right ventricular function is good.  In this patients case, the tricuspid valve needs to be repaired in order for him to be a candidate for the next stage repair Fontan.  Based on the medical records and review of the medical literature, the request for surgical repair of the tricuspid valve is medically necessary in order to preserve right ventricular function and make the patient a better candidate for the Fontan procedure.  The left pulmonary artery repair is also medically indicated based upon the clinical documentation.  Early left pulmonary artery repair will promote growth of the artery and left lung and may make him a better Fontan candidate in the future.  All told, repair of the transverse arch and tricuspid valvuloplasty are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested for Suboxone therapy for treatment of her chemical dependency. Findings:  The physician reviewer found that this patient manifested a range of symptoms and has experienced adverse consequences as a result of her opioid addiction. She has had anxiety and multiple legal difficulties as a result of her addiction. The patient relapsed and did not follow directions expected of her with the medication contract. This can be an expected outcome of severe addiction. Patients who relapse using a Suboxone intervention should be treated with more intensive and comprehensive treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested occipital nerve stimulation for treatment of his headaches. Findings:  Two physician reviewers found that occipital nerve stimulation is not likely to be more beneficial for the treatment of the patients medical condition than other treatment modalities.  Per the peer-reviewed literature, anticonvulsant medications, antidepressants, beta blockers and triptans are considered to be safe and efficacious therapy for chronic headaches.   This patient presents with a more complicated picture of headaches than solely occipital neuralgia, and there is a paucity of peer-reviewed literature to support the requested services over standard therapy for chronic headaches.  Thus, the requested occipital nerve stimulation is not likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryosurgical ablation of the left breast (CPT 19105). The National Comprehensive Cancer Network guidelines for the treatment of breast cancer note that the use of pembrolizumab is limited to intravenous therapy and may be used in combination with chemotherapy. The U.S. Food and Drug Administration (FDA) notes that Keytruda (generic name pembrolizumab) injections may be used in combination with chemotherapy. Current medical literature and guidelines do not support the use of pembrolizumab as a direct intratumoral injection. In this case, the records did not indicate that the patient was participating in clinical trials, and the use of cryoablation and an intratumoral injection is not supported over conventional care options such as a mastectomy. Therefore, cryosurgical ablation of the left breast (CPT 19105) was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found cryosurgical ablation of the left breast (CPT 19105) was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology 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

A 51-year-old female enrollee has requested bilateral upper eyelid blepharoplasties for treatment of her dermatochalasis.  Findings:  The physician reviewer found that the patient must have a complaint related to drooping eyelids in terms of visual function, and this complaint must be documented in the clinical record along with a plan for treatment. In addition, photographs must display impingement of the edge of the drooping upper eyelid margin of 2.5 mm or less from the pupillary light reflex (Federici, et al). Finally, if the above two criteria are met, a visual field test must show a minimum of 12 degrees or 30% loss of superior visual field, and improvement with the lids taped up. This patients photographs, documentation, and automated perimetry do not fulfill the criteria for the requested procedure to be considered medically necessary. Therefore, the requested procedure is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient rehabilitation. Spinal cord injury can result in profound functional impairments generally requiring complex, individualized rehabilitative measures. The patient in this case sustained severe trauma to her spine, with clear clinical indications of paraplegia, as well as trauma to right lower extremity, due to a fall. There is ongoing loss of volitional motor function in the lower limbs, which is acute in nature. The patient is in need of rehabilitation to address functional deficits in light of this development. There is also a question of whether the patient has control of bowels and bladder. The patients course has been significantly complicated by psychiatric condition and cognitive impairments, including poor insight into patients condition. The patient has had paranoid ideations and has been uncooperative with medical, nursing and therapy assessments, and interventions. Patient has refused to wear the spinal orthosis ordered to be worn when out of bed. Limited participation has persisted despite ongoing psychiatric management, with adjustments to her psychotropic pharmacotherapy. At this stage, the patient is not a candidate for acute inpatient rehabilitation as there is an absence of documentation supporting that she would be expected to participate and benefit from intensive rehabilitation. According to the American Academy of Physical Medicine and Rehabilitation, acute inpatient rehabilitation is not indicated if a patient is unable to participate in and benefit from an intensive rehabilitation program. Despite the patients impairments and clinical issues, acute inpatient rehabilitation is not medically necessary. The patient has a guarded to poor prognosis due to the nature of the pathologies following her trauma, as well as her pre-existing psychiatric comorbidity. All told, the requested inpatient rehabilitation is 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 physical medicine and rehabilitation 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 been diagnosed with right knee osteoarthritis and left knee pain with moderately advanced arthritis. On 10/23/19, the patient received a right knee steroid injection. The provider recommended physical therapy, focusing on strength and range of motion of the lower extremities. The patient reported being unable to ambulate due to bilateral knee pain. The patient was noted to be severely deconditioned and morbidly obese. The patient has received viscosupplementation injections in the past, with good results. Physical examination findings included tenderness over the knee medial and lateral joint lines. Left knee steroid injection was administered. The patient has requested authorization and coverage for Euflexxa injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in both knees are medically necessary for the 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 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 mastectomy. The records document that this patient has gynecomastia, which is an abnormal structure of the body. However, the patients medical condition is not attributed to congenital abnormalities, developmental abnormalities, trauma, infection, tumors and disease. Moreover, the records do not document any health or functional problems caused by the patients enlarged breasts. This patients records do not document any concern for breast cancer. The procedure will primarily improve the patients appearance and therefore is cosmetic. Observation, reassurance and use of analgesics are reasonable management approaches for this patients condition. All told, the requested mastectomy is not supported as medically necessary or reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female has requested breast reduction surgery (reduction mammaplasty) for treatment of her breast hypertrophy and mechanical ptosis.  Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, skin breakdown, if they are present. To further delineate this group of patients a Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery prior to surgery. Given the absence of any breast cancer, the amount removed is increased as the procedure changes from a cosmetic procedure to a medically necessary reconstructive procedure. The aforementioned scale accounts for this by relating the amount removed to body surface area, or size of the patient, rather than just weight or height. In this case the proposed surgery with removal of 500 to 600gm from each breast does not meet these criteria. Furthermore, this patient is obese, which has been shown to result in higher complication rates and greater dissatisfaction with results of breast surgery than patients closer to ideal body weight. This more frequently results in additional secondary or revision breast operations, so the optimal approach is weight loss, surgical or otherwise, prior to breast surgery, if it is indicated. Given that this patient has not failed other conservative treatment methods and the proposed removal amount does not meet the criteria specified on the Schnur scale, the requested bilateral breast reduction (reduction mammaplasty) is not medically necessary for treatment of the patients medical condition.