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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested surgical breast augmentation for treatment of her gender dysphoria.  Findings:  The physician reviewer found that the patient is a transgender female with well-documented gender dysphoria who has been undergoing female transitioning for an extended period of time with hormonal therapy. Based upon the clinical evidence provided, despite extensive hormonal therapy, the patient does not have evidence of sufficient breast development consistent with adult female anatomy. The American Society of Plastic Surgeons (ASPS) has adopted the following definitions: Cosmetic surgery is performed to reshape normal structures of the body in order to improve a patients appearance and self-esteem. 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 done to approximate a normal appearance.  In this patients case, she is well-documented to have gender dysphoria; thus, her external anatomy should be more consistent with a female than a male. As such, the requested surgical breast augmentation is medically necessary for treatment of her gender dysphoria. Currently, her examination and photographs depict a lack of breast development and is more consistent with male anatomy. Thus, this should be considered breast reconstruction of a patient with lack of breast development. The abnormal structure of the body is caused by a lack of adequate response to hormonal therapy, a developmental abnormality. Based on the photographs and medical documentation provided, the patient has a significantly abnormal appearance and any appropriate surgical correction would attempt to obtain a more normal appearance and is likely to result in more than minimal improvement. As such, the requested service is medically necessary and considered reconstructive in nature. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number three 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 56-year-old female enrollee has requested authorization and coverage for Orthovisc injections for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that The issue in this case is whether the requested medication, Orthovisc, is medically necessary for the treatment of the patient. The use of hyaluronans such as Orthovisc in the treatment of osteoarthritis of the knee has been generally accepted (Bellamy, et al.), and is most suitable for patients with mild to moderate disease (Dagenais, et al.) with no or mild effusion (Gossec and Dougados). The available evidence of the effects of multiple courses of therapy on outcomes is not sufficient to reach firm conclusions (Espallargues and Pons). Although some studies have been encouraging (Raynauld, et al.), problems such as painful acute local reaction have been reported with repeated courses of treatment (Morton, et al.). Additional studies are in progress, but the results are not yet available. In the absence of adequate data supporting the safety and efficacy of repeated courses of intra-articular hyaluronan injections, the requested medication is not medically necessary for treatment of this patients condition. Therefore, the Health Plans denial was appropriate.
Appeal type: Urgent Care
Decision: Upheld

A 40-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient was diagnosed with sinusitis, prescribed an oral antibiotic and discharged.The prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms were not sudden on onset but had been present for one week. There was no acute change in her condition such as shortness of breath or chest pain. No emergent medical intervention was required.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg-100 mg for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50 mg-100 mg for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.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 gastroenterology 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 reimbursement and prospective authorization and coverage for 35 hours per week of one-on-one applied behavioral analysis (ABA) therapy, 15 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism. Findings:  The physician reviewer found that the patient has behavioral issues that include disruptive behavior and vocal stereotypy. There is sufficient support that ABA therapy is effective for addressing these behaviors. Thus, ABA services are clinically indicated. However, the patients maladaptive behaviors have not changed or slightly increased per the most recent progress report.  Based on the clinical documentation submitted for review, a reduction in ABA hours is appropriate for this patient. A rapid reduction in services can increase maladaptive behaviors. Thus, 32 hours per week of one-on-one ABA therapy, 15 hours per month of supervision and two hours per month of parent training provided were and is medically necessary and appropriate for treatment of the patients autism. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 right knee joint replacement surgery. Current guidelines recommend total knee replacement as a reliable and suitable surgical procedure to return highly symptomatic patients to better function. The most common indicated diagnosis is advanced osteoarthritis. Indications for surgery include failure of conservative treatment, including exercise therapy and medications, subjective findings of stiffness, nighttime joint pain, minimal pain relief with conservative care, current significant functional limitations, age over 50 years, body mass index less than 40, and x-ray findings of significant osteoarthritis. In this patients case, she presents with persistent significant right knee pain with associated swelling, clicking, catching and giving out. Functional limitations have been noted. This patients symptoms and clinical examination are consistent with radiographic evidence of tricompartmental osteoarthritis, end-stage in the lateral compartment with valgus deformity. There is documentation of long-term comprehensive nonoperative treatment, including bracing, ambulatory assistive devices, NSAIDs, physical therapy, activity modification, and corticosteroid injections, without sustained improvement. There is sufficient support for the requested services in this clinical setting. Thus, the requested right knee joint replacement surgery is 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive patients with genotype 2 hepatitis C should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage.  AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology 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 54-year-old male with a slightly elevated PSA at 4.23 who on ultrasound-guided prostate biopsy on 3/11/05 was found to have mid-grade (Gleason total 6 out of 10) adenocarcinoma in the left base of his prostate. The patient has requested surgical treatment of this cancer, specifically, a robotic-assisted laparoscopic radical retropubic prostatectomy. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications and is considered standard of care for treatment of the patients prostate adenocarcinoma. Therefore, I have determined that the requested procedure is 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: An enrollee has requested reimbursement for the medication tramadol. Pursuant to national guidelines, opioids are recommended at the lowest effective dose for the anticipated time duration of pain that is severe enough to require opioids. A therapeutic trial of opioids should not be employed until the patient has failed a trial of non-opioid analgesics. The recommended time ranges from 3 to 7 days, as indicated in the CDC Guideline for Prescribing Opioids for Chronic Pain. These recommendations are primarily based on emergency department guidelines and related literature. Some conditions may require longer use of opioids, including instances that relate to severe trauma or involve patients requiring major surgery. Most recommendations in this regard are based on consensus, with an upper range of use, of approximately 6 weeks, with weaning ongoing after approximately 7-10 days. The CDC has recommended re-evaluation of patients who continue to have pain for longer durations than expected. This allows for confirmation of diagnosis or adjustments in treatment. The recommended formulation for treatment of acute pain should be immediate-release and not extended release/long-acting. In this case, the cited criteria for prescribing opioids have not been met. The patient was evaluated and treated for an episode of acute low back pain with radiculopathy. The clinical note of the patients first evaluation does not quantify the severity of the enrollee's pain using a validated outcome score or a visual analog scale to establish that his pain was severe enough to warrant an opioid prescription. There is no documentation of a failed trial of non-opioid analgesics and other conservative care (exercise/heat/ice/activity modifications/physical therapy) prior to prescribing opioids. Furthermore, the refills continued beyond the recommended 7 days of treatment for acute pain. Under these circumstances, the medication tramadol that was provided was not medically necessary for treatment of the patients medical condition.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 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: Overturned

A 48-year-old female enrollee has requested the FlexiTouch System for the treatment of her lymphedema. Findings:  Three physician reviewers found that the FlexiTouch System obtained FDA approval in 2002 and again in 2006 (for additional indications) and has demonstrated proven efficacy and benefit. It has been a well-accepted and prescribed treatment for over four years. This patients specific condition can be effectively treated with the FlexiTouch device. At this time, there are no other at home therapy devices as effective as the FlexiTouch System for this patients condition. The other types of standard therapy have been of little or no benefit for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement for partial hospitalization program services received. Findings:  The physician reviewer found that  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 2. The patient had chronic poor impulse control, reactivity, history of suicide attempts, and drug use. The patient is assessed as having some risk of harm given her history; however, she no longer endorsed suicidal ideation and there did not appear to be acute safety issues.In terms of functional status, the records support a score of 3. The patient has a history of compromised functioning including bullying parents, not attending school, substance abuse, depression, anxiety, suicidal ideation, past suicide attempts, and a history of food restriction. With regard to comorbidity, the records support a score of 3. The patient had attention deficit hyperactivity disorder (ADHD), depression, and substance use.In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has had chronic severe and stressful relational challenges with her parents. The patient has a history of being explosive and reactive towards her family. With regard to level of support of the recovery environment, the records support a score of 3 due to continued limited support in the family. There are also chronic family dynamic concerns.In terms of resiliency and treatment history, the records support a score of 3. The patient has had outpatient follow-up, with limited results. The patient appears to have responded to some degree to RTC and partial hospitalization program treatment, but there are also concerns for minimizing symptoms so she can be discharged.With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears to have some constructive engagement while in treatment, but tended to want to push family away. Thus, the patient has a total score of 21. Thus, the records support Level 4 Medically Monitored Community Based Services. The documentation supports the medical necessity of partial hospitalization program in this patients case. Therefore, partial hospitalization program services received were medically necessary for treatment of the patients medical condition.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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brachytherapy, image-guided radiation therapy (IGRT), and special radiation physics consultation for radiation therapy. The records document that this patient has a history of estrogen receptor (ER) positive, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative right breast cancer. Following delivery of her child, this patients is planned to undergo radiation therapy with delivery of an initial photon-based external beam radiation treatment to the whole breast, followed by the boost treatment delivered with AccuBoost brachytherapy. The National Comprehensive Cancer Network (NCCN) guidelines recommend a course of adjuvant radiation treatment to the resected breast after a lumpectomy for patients with breast cancer in this patients clinical setting. The boost treatment is a dose focused on a small area of the breast that follows the initial treatment. The purpose of the boost is to administer a higher dose to the high-risk region of the breast, typically the lumpectomy site, without increasing the dose to the remainder of the breast. As recommended by the NCCN guidelines, there are several methods to deliver this boost including electrons, photons, and brachytherapy. For this patient, there are a few concerns regarding radiation dosing including complex and unusual anatomy as reported by the provider. Brachytherapy has the benefit of conformality since it may be inserted into or positioned around the lumpectomy cavity to reduce the amount of adjacent tissue exposure (Kauer-Dorner and Berger). Overexposure of the adjacent lung can lead to toxicities such as radiation pneumonitis or chronic pain from costochondritis. Moreover, given the patients young age, the risk of a secondary radiation-induced malignancy is correlated with the amount of tissue irradiated and results in a higher lifetime risk of secondary malignancy in comparison to more elderly patients (Xie, et al.). For these reasons, the requested brachytherapy with IGRT and special radiation physics consultation for radiation therapy are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 55-year-old female enrollee has requested chiropractic services for the treatment of her back pain. Findings:  The physician reviewer found that there is sufficient evidence in this patients case to support the medical necessity of chiropractic services. The submitted records document the presence of altered spinal alignment, a decline in spinal motion and integrity, and an altered physiological function of the spine. Chiropractors are neuromuscular specialists and have particular expertise in managing these issues. The patient has reported good results from chiropractic care in the past and is likely to benefit from additional chiropractic treatment. She has undergone multiple other modalities without adequate relief. Furthermore, she experiences gastrointestinal upset from pain medication. Chiropractic services are the next appropriate step for this patient and should be authorized.