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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for facial feminization surgeries (CPT 21137 reduction forehead contouring; CPT 67900 repair brow ptosis; CPT 21139 reduction forehead; contouring and setback of anterior frontal sinus wall; CPT 30410 rhinoplasty, primary; complete, external parts including body pyramid, lateral and alar cartilages, and/or elevation of nasal tip; CPT 21122 genioplasty; sliding osteotomies, two or more osteotomies;  CPT 21209 osteoplasty, facial bones; reduction). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. Moreover, the World Professional Association for Transgender Health (WPATH) supports facial feminization surgery in well-selected patients. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. In addition, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Researchers demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. In this case, the therapist attests to the medical necessity of the requested facial feminization surgeries, given the patients distress related to the presence of her masculine facial features. Moreover, the surgeon described the patients specific masculine facial features that will be addressed with the requested surgical procedures. All told, the requested facial feminization surgeries (CPT 21137 reduction forehead contouring; CPT 67900 repair brow ptosis; CPT 21139 reduction forehead; contouring and setback of anterior frontal sinus wall; CPT 30410 rhinoplasty, primary; complete, external parts including body pyramid, lateral and alar cartilages, and/or elevation of nasal tip; CPT 21122 genioplasty; sliding osteotomies, two or more osteotomies;  CPT 21209 osteoplasty, facial bones; reduction) 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 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 reimbursement and prospective authorization and coverage for continued mental health inpatient level of care services and electroconvulsive therapy (ECT).Findings: Per the Centers for Disease Control and Prevention (CDC), this patient has multiple risk factors concerning for suicide including a family history of suicide and previous suicide attempts. In addition, he has a history of depression and substance abuse and he has endorsed feelings of hopelessness and isolation. The records indicate that ECT has improved the patients mood but that he remains at significant risk. The American Psychiatric Association (APA) guideline states that, measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. Further, the APA noted that, ECT is recommended as a treatment of choice for patients with severe major depressive disorder that is not responsive to psychotherapeutic and/or pharmacological interventions, particularly in those who have significant functional impairment or have not responded to numerous medication trials. This patients illness is severe and he has failed multiple medication trials. As per Fink and colleagues, the rapid relief of severe depression, mania, and psychosis by ECT is accompanied by the rapid reduction in suicide drive. Given this patients ongoing suicide risk, he still meets criteria for inpatient hospitalization and treatment with ECT. Therefore, continued mental health inpatient level of care services and ECT provided was and is 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 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: A patient has requested authorization and coverage for Norco. The submitted documentation does not support the medical necessity of the requested medication. Opioids are not first-line medications for osteoarthritis of the hip or for chronic low back pain. The American College of Rheumatology recommends trials of acetaminophen, oral and topical nonsteroidal anti-inflammatory drugs, tramadol and intra-articular injections of corticosteroids. The records did not indicate that these modalities have been used exhausted. Long-term use of opiates is not recommended outside of a defined pain management plan, including a formal risk assessment and urine toxicology screening. Therefore, Norco is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-specialty certification in pain 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

This patient is an nine-year-old female who has been receiving speech therapy for pragmatic language delay and auditory processing deficits. Specifically, the test of auditory perceptual skills showed deficits in auditory sentence memory, auditory word memory and auditory word discrimination. The test of pragmatic language put the student in the 73rd percentile with a standard score of 109 (mean standard score 100). The therapist felt however, the test did not discriminate her difficulties with describing, placement and sequencing of events. The summary recommendations from the Standardized testing deal primarily with school modification and involvement in social/pragmatic groups. School observation recommendations are also geared toward modification of the school environment. The reports do not include a formal diagnosis of speech and language deficits and neither of the summaries expressly recommend speech therapy.  The parents request for reimbursement for speech therapy provided from September 2005 through October 2005 was denied by the Health Plan based upon a determination that the therapy was not medically necessary.The establishment of a diagnosis in the area of speech and language deficits is essential to effective speech therapy.  In this case, no such diagnosis was made and the patients symptoms may be caused by deficits in other areas. Secondly, as documented, the deficits are educationally based issues and not directly related to specific speech or language deficits. Lastly, it is also essential that formal goals be developed to direct the course of the speech therapy and to measure the patients progress.  The frequency of the intervention should also be specified.  The formal reports provided here do not include goals for the improvement of speech and language skills, a measure of the patients progress to such goals, or a recommended frequency for the provision of speech therapy.  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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that a diagnosis of autism requires accumulating evidence from multiple sources, such as parent and teacher reports, clinical rating scales, and direct observation. In this case however, there are three evaluations. The first two conclude with a diagnosis of autism. The third evaluation finds that the patient does not have autism. The key differences between the evaluations are the differences in eye contact, shared activity, and quest for praise. These are noted as present in the most recent evaluation, but absent in the prior ones. This discrepancy may be due to differences in the examiner, differences in the behaviors of the patient on a day to day basis, or perhaps improvement/change in the patient between the examinations. However, it seems prudent to put the most weight on the most recent examination for multiple reasons. The most recent evaluation describes traits not seen in autistic children, and which are unlikely to fluctuate from exam to exam. In addition, the most recent evaluation comprises a large interdisciplinary team. Thus, the records submitted for review do not support a diagnosis of autism. As such, the requested ABA services are not medically necessary for treatment of the patients medical condition.  Final Result: Two reviewers determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatric neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for testing for assay of apolipoprotein. The records document that this patient has established CAD. Per the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines, treatment in this clinical setting includes achievement of LDL cholesterol goals with intensive lifestyle and pharmacologic lipid lowering therapy, which is currently being done (Arnett, et al.). Although there is some emerging observational, population based data that apolipoprotein measurements may have utility in determining residual risk in patients with goal or near goal LDL cholesterol levels, the data is mixed at present and current guidelines do not recommend the use of repeated measurements to guide lipid lowering therapy (Stone and Lloyd-Jones; Welsh, et al.). Similarly, repeated advanced lipoprotein measurements to guide lipid lowering therapy are not considered consistent with current AHA/ACC guidelines. For these reasons, the testing for assay of apolipoprotein was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the testing for assay of apolipoprotein 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 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 1 is board certified in certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology 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: Experimental/Investigational
Decision: Upheld

A 53-year-old male requested authorization and coverage of laparoscopic prostatectomy. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees prostate cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica (pregabalin) capsule 75 mg. This patients records document degenerative arthritis and possible myofascial pain syndrome. However, her provider did not document specific tender points on physical examination, qualifying the patient for a diagnosis of fibromyalgia. In addition, there is no documentation of increased intraocular pressure or glaucoma to demonstrate that tricyclic antidepressants or muscle relaxants are contraindicated in this patient. Although the patient has been treated with gabapentin, Cymbalta, and amitriptyline, none of these medications was tried at a therapeutic maximized dose. Moreover, the records do not include documentation that the patient has exhausted behavioral therapies for management of her condition. All told, the requested Lyrica (pregabalin) capsule 75 mg is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Durolane injection into both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections received two years ago. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Durolane injection into both knees 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser IFX testing. Patients with low infliximab concentrations and high titers of antibodies to infliximab will most likely require treatment with a different agent. Some providers advocate for the use of monitoring infliximab trough levels at week 14, permitting dose escalation before the development of clinical or laboratory evidence of disease activity. In randomized trials comparing therapeutic drug monitoring with routine management, therapeutic monitoring was associated with fewer relapses. All told, the Prometheus Anser IFX testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Prometheus Anser IFX testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the Prometheus Anser IFX testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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 authorization and coverage for uvulopalatopharyngoplasty (UPPP) procedure. Although continuous positive airway pressure (CPAP) is considered first-line therapy for OSA, it is also associated with a 25-50% non-adherence rate. This patient is considered non-adherent as he has been unable to tolerate CPAP. One meta-analysis found that objective and subjective sleep-related outcomes improved significantly after UPPP for at least 34 months postoperatively (He, et al.). A systematic review found that CPAP non-adherence rates could be as high as 33% in many CPAP clinical trials, with a likely reduction in clinically meaningful benefit (Rotenberg, et al.). The study found a greater mortality among CPAP users compared to those who underwent UPPP for OSA, even after adjusting for age, gender, race, year of treatment, and comorbidities. Surgical risks are weighed against the risks of untreated OSA, including cardiovascular disease, hypertension, cognitive dysfunction and depression . This patient presents with severe OSA. His treatment has included an appropriate trial of CPAP, yet he has been unable to obtain substantial benefit from the device due to intolerance. Based on available clinical documentation, the requested UPPP procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested UPPP is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested radiofrequency ablation for medical treatment of her fibroid tumor.  Findings:  Two physician reviewers found that ultrasound guided radiofrequency ablation is a promising procedure for the treatment of uterine fibroids. Short-term studies suggest its effectiveness with minimal side effects. However, studies with longer follow-up are still underway, so the long-term effectiveness and side effects have not yet been established. Overall, there is a lack of peer-reviewed medical evidence that radiofrequency ablation is likely to be more beneficial for the treatment of this patients symptomatic fibroids than standard therapies such as uterine artery embolization, myomectomy, or hysterectomy.