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

A 47-year-old female enrollee has requested a bilateral capsulectomy mammaplasty with bilateral removal of mammary implants for treatment of her bilateral breast and nipple pain. Findings:  The physician reviewer found that if there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, removal of the implant with capsulectomy (CPT 19371) would be considered medically necessary and not cosmetic. Removal of the capsule and implant with or without placement of a new implant should alleviate the pain and will prevent migration of the gel to adjacent areas where it could cause additional medical problems. Surgery for visible but non-painful capsular contracture (Grade III) or palpable but not visible or painful capsules (Grade II) would be considered cosmetic and not medically necessary. This patient had intact saline implants with Baker grade III contractures. Furthermore, she did not have other conditions such as infected implants, extruding implants, breast cancer, silicone gel breast implant rupture or documented chronic clinically significant symptoms related to the implants that would make their removal medically necessary. Therefore, the surgery performed on the said date was not medically necessary for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for ThyGenX thyroid panel. The Health Plan has denied this request indicating that the services at issue were considered investigational for the evaluation of the enrollees indeterminate thyroid nodule.Findings:  While FNA biopsy of a suspicious thyroid nodule is an accurate means of assessing whether the nodule is benign or malignant, researchers found approximately 15% of FNA biopsy results are considered indeterminate. Until recently, studies have shown that 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 development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value, thereby, obviating the need for unnecessary surgeries. For the reasons stated above, ThyGenX thyroid panel was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: Two of the three reviewers have determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Siliq. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology (AAD), patients who have psoriasis affecting between 3-10% of their body surface area (BSA) is defined as moderate, while patients with more than 10% BSA involvement have severe disease and are candidates for systemic medical therapy. There is a lack of step therapy guidelines for use in this clinical setting. Siliq is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis with adequate evidence to support its safety and efficacy. This patient has a documented history of severe disease recalcitrant to several therapies, but he experienced symptomatic relief with Siliq. Given this support, the requested Siliq 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 dermatology with subspecialty certification in dermatopathology 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 for a panniculectomy for treatment of her excess abdominal skin, secondary to Roux-en-Y gastric bypass surgery. Findings:  The physician reviewer found that there is minimal documentation  to support the need for panniculectomy.  Following a significant weight loss, the patient would be expected to have loose abdominal skin, but this does not necessarily mean she would have a functional deficit. Although the patient states in her appeal that she has a serious condition, the submitted medical records do not describe signs or symptoms to suggest that the patient has a significant functional problem related to her abdominal pannus.  The American Society of Plastic Surgeons (ASPS) position on insurance coverage states, When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure.  Since a functional deficit has not been defined by the patient or the provider, the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested for eating disorder partial hospitalization program services for treatment her behavioral health condition. Findings:  The physician reviewer found that the patient appears to lack motivation for treatment as judged by her lack of treatment compliance with the IOP. In ED patients, this non-compliance is more likely resistance to engage in activities in treatment that bring out emotional pain. National guidelines remain unclear as to the appropriate level of care for most ED patients. This appears not only to the inpatient level of care but lower levels of care as well. The literature supports the fact that patients generally remain at their discharge level of recovery over time (see Zeeck and colleagues). This patient has remained at a consistent level of dysfunction since the decrease in her services and is likely to continue to deteriorate at her current level of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. Applying the ASAM guidelines, this patient meets the criteria for RTC services. The patient has post-acute withdrawal symptoms of anxiety, agitation, and tremors. The patients Clinical Opiate Withdrawal Scale (COWS) score was 10 and her pulse was elevated at 106. She has been treated with Zubsolv in addition to Sublocade. The patient has type I diabetes. She is on insulin but does not follow her recommended diet and her sugar levels range from 64-289. Her medical condition distracts from her recovery. The patient is noted to have comorbid PTSD and bipolar disorder. She demonstrated numerous symptoms of hypomania on admission and has longstanding difficulties with impulse control and distractibility due to mild cognitive impairment. She has history of non-adherence with psychiatric medications. The patient has exhibited difficulty with impulse control in the community despite being residing in a sober living facility. She relapsed while there due to feeling depressed and not having the skills to manage her emotions. She continues to require structured therapy and a 24-hour program milieu. The patient has experienced ongoing cravings to use heroin. She is being stabilized with daily Sublocade injection and Zubsolv. She has undergone repeated treatment episodes with little positive effect on her level of functioning. She has poor skills to cope with and interrupt her issues with addiction. The patient is currently homeless and her social environment consists of others who abuse drugs. Given these findings, the RTC level of care services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 expertise 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The American Society of Addiction Medicine (ASAM) has established a series of six dimensions to create a holistic, biopsychosocial assessment of an individual to be used for service planning and treatment across all services and levels of care. The six dimensions are: dimension 1) acute intoxication and/or withdrawal potential; dimension 2) biomedical conditions and complications; dimension 3) emotional, behavioral, or cognitive conditions and complications; dimension 4) readiness to change; dimension 5) relapse, continued use or continued problem potential; and dimension 6) recovery/living environment. The American Society of Addiction Medicine criteria for level of placement can be applied to this patients presentation to help determine the appropriate level of care. In this patients case, the records do not document that the patient met dimension 1 (acute intoxication and/or withdrawal potential) or dimension 2 (biomedical condition and complications). In order to meet ASAM criteria for the residential treatment level of care for adults, the patients presentation must meet all six criteria. Therefore, residential treatment center services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that based on the documentation submitted for review, RTC services were and are medically necessary for treatment of the patients medical condition. In this case, the patient meets clinical criteria for continued stay at the RTC level of care. He has a long history of both psychopathology and substance abuse requiring treatment. He has made serious attempts to kill himself in the past, and continues to have many positive risk factors for suicide. In addition, he has received only short-term treatment, and then discharged to a less restrictive environment only to relapse. He has had poor compliance with treatment in the past, which requires the structure and 24-hour setting of RTC. Of note, the patients risk factors for self-harm include a history of previous suicide attempts with clear intent to harm himself and no barriers to access of means to harm himself. Given the patients previous premature discharges, continued RTC services are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue are and 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 with sub-specialty 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: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that the literature and experience of headache specialists supports the use of Botox for chronic migraine. It is currently used with some frequency in patients who have failed multiple standard therapies and have moderate to severe migraine-related disability. The records that this patient has provided do not document migraine and do not include mention of prior therapy utilization. In addition, the submitted documentation does not document response to Botox and does not document frequency and severity of current headaches. The patient does indicate that she has been under the care of a headache specialist, suggesting that at some point in time she likely had a severe and disabling headache disorder. The injection sites and doses suggest a cosmetic paradigm, although the treating physician indicates that it is for migraine. Given the lack of information about this patients headache disorder, it has not been demonstrated that Botox injections are likely to be more efficacious for this patient than alternative treatments.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for segmental pneumatic compressor, trunk (E0656). This patient presents with chronic inflammation and edema in the legs and abdomen status post oophorectomy. The patient has been treated with manual lymphatic drainage, elevation, exercise, and compression without substantial improvement. Her provider has recommended a segmental pneumatic compressor for the trunk. Intermittent pneumatic compression using a pump with leg garment can potentially be a useful complement for maintenance edema management, with the foundation of care being compression garments. However, intermittent pneumatic compression is not a substitute for appropriate conservative care, particularly given that intermittent pneumatic compression may cause complications and may not be well tolerated (Chang and Cormier). Moreover, there is a lack of data demonstrating a clinical benefit with an intermittent pneumatic compression device that includes a truncal garment extension. The truncal garment extension has not been shown to improve patient health outcomes in the treatment of lymphedema or lipedema in the lower body. Given these findings, the requested segmental pneumatic compressor, trunk (E0656) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 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: A patient has requested reimbursement for the residential substance abuse treatment services provided from 4/25/18 through 5/18/18.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills, and drug-free social supports to maintain abstinence in an outpatient setting. A study showed that following a brief  three-week period of abstinence and participation in a psycho-educational program, the alcohol dependent group in the study demonstrated significant improvements in relation to depression, anxiety, and 13 out of 15 maladaptive schema beliefs. Following detoxification treatment, the standard rehabilitation program is a 30-day residential treatment, which was in accordance with generally accepted standards of medical practice, clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and was therefore medically necessary. Therefore, the residential substance abuse treatment services provided from 4/25/18 through 5/18/18 were 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

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Genotropin. The submitted documentation demonstrates the medical necessity of the requested medication. The records document short stature. To the extent that the question of Hashimoto thyroiditis and hypothyroidism arises as possibly causal for the short stature, it is noteworthy that the patients elevation of thyroid stimulating hormone was so mild has to preclude the possibility of lasting clinical consequence of hypothyroidism on stature specifically. Ongoing therapy with growth hormone is warranted in this context. The patients annualized velocity on growth hormone has improved, indicating a positive response, which warrants continued therapy. Therefore, Genotropin is 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 authorization and coverage for minimally invasive urologic surgery. The records provided for review document that the patient has been diagnosed with left ureter transitional cell carcinoma (UTUC). The provider referred the patient for surgery. The provider states that the patient will undergo this surgery within three months of initial diagnosis. The patient is requesting surgery within one month of diagnosis. However, current medical literature does not support improved outcomes in patients who undergo surgery less than three months versus delayed surgery. Researchers concluded that their results showed no difference in survival between patients undergoing early versus delayed extirpative surgery for UTUC. Therefore, the requested minimally invasive urologic surgery is not medically necessary for treatment of this patients medical condition. 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 urology 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 36-year-old female enrollee has requested for laparoscopic band gastric surgery (bariatric lap band for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the guidelines set by the National Institutes of Health for weight loss surgery. There is a large amount of data that shows that non-surgical methods of weight control are inferior to surgical procedures.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, she has breasts that have been described as being heterogeneously dense.  First, the new mass that was discovered in the lower outer aspect of the left breast was an appropriate indication for breast tomosynthesis. Second, the area of asymmetry is another indication for breast tomosynthesis. Final Result: The reviewers have 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: Reviewers 1, 2 and 3 are board certified in diagnostic radiology 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.