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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rhinoplasty with the approved septoplasty. The records provided for review document that this patient has a symptomatic deviated nasal septum as a result of trauma, and correction of the deviated nasal septum has been authorized. In addition, the patient has a bump on his nose that is secondary to the same trauma. The records do not document any deviation of the nasal bones or breathing obstruction medically attributable to the bump on the nose. Thus, correction of the nasal bump would not be to improve a functional deficit. Spataro and Most noted that, physical examination findings are subjective and prone to bias. Although observer assessments are found to be sensitive for identifying anatomic deformities, they have low specificity in relation to subjective measures, meaning that clinicians may identify deformities that are not clinically significant. Karaogullarindan and colleagues stated that, significant septal deviation is nearly always a component of the deviated nose and that the degree of dorsal deviation correlates highly with patient-reported nasal obstruction. Based on the available documentation and medical literature, the requested rhinoplasty with the approved septoplasty is not medically necessary to treat the patients medical condition.The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Based on the medical information received for review, the patients nasal deformity constitutes an abnormal structure of the body caused by trauma. Correction of the bump will not improve function based on the available documentation. However, the records support that the requested rhinoplasty with the approved septoplasty would create a more than minimal improvement in the patients appearance. Therefore, the requested rhinoplasty with the approved septoplasty is reconstructive in nature, and thus medically necessary, for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections under sedation. On review of the available medical literature, Botox treatment of this patients pelvic pain, is not supported as likely to be more beneficial than standard available therapies. The records indicate that the source of the patients pelvic pain has not been identified. Botox has been shown to be promising in the treatment of certain pelvic pain situations. However, additional studies have been recommended to endorse treatment with Botox for specific pelvic pain indications. Dessie and colleagues concluded that pelvic floor Botox injections for myofascial pelvic pain were not more effective than saline injections at decreasing muscle pain on palpation. Although Meister and colleagues reported promising preliminary findings, the authors noted that large scale randomized controlled trials are needed to determine the safety and efficacy of Botox injections for the treatment of patients with pelvic floor myofascial pain. For these reasons, the requested Botox injections under sedation are not 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 services are not 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 not likely to be 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 reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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 forty-seven year-old female who has unattractive scars following a thyroidectomy is requesting authorization for scar revision surgery.Reviewers Findings:The reviewing physician found that the patient is concerned about the aesthetic appearance of the scars, but the records provided do not document that the scars are causing a functional problem such as pain or pruritus.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers 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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions (Class I, Level A recommendation). Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested speech therapy for treatment of his Aspergers syndrome. Findings:  The physician reviewer found that the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). Therefore, it is medically necessary and appropriate for this patient to undergo individual speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX CPT code 0392T. Findings:  Three physician reviewers found that the LINX device has been approved by the U.S. Food and Drug Administration for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  In this patients case, he is symptomatic, but there is no objective evidence of esophagitis and his available record documents subjective response to conventional medical therapy. As such, he cannot be considered medically refractory to acid blocker drugs. Thus, LINX CPT code 0392T is not likely to be more beneficial than the available standard therapy for treatment of this patients medical condition. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ibrance capsules.Findings: Three out of three physician reviewers found that the requested medication, Ibrance  capsules, is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Ibrance (palbociclib) is FDA approved for the treatment of metastatic breast cancer in combination with fulvestrant or an aromatase inhibitor. Ibrance does not have off-label indications at this time. Low-grade serous ovarian cancers are known to respond to aromatase inhibitors. Based on this, there are two ongoing trials looking at CDK 4/6 inhibitors letrozole with ribociclib and fulvestrant with abemaciclib. A trial of palbociclib with and without trametinib showed poor activity. A case report involving combination therapy of palbociclib with letrozole has noted a continued response to treatment. In this case, however, the request is for single agent therapy. Under these circumstances, the requested medication is unlikely to be more beneficial than any available standard therapy. Therefore, the requested medication, Ibrance capsules, is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine, with subspecialty certifications in medical oncology and hematology, and are actively practicing. Physician reviewer 3 is board certified in internal medicine, with subspecialty 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: Overturned

The patient is a 49-year-old woman with chronic migraine, chronic hip pain, insomnia and excessive daytime somnolence (EDS) who is requesting coverage for Provigil. She tried Provigil and finds it resolves her symptoms and substantially improves her quality of life. She apparently has been unable to reduce her other medications due to an increase in her chronic pain.  The patients request for authorization and coverage of Provigil was denied by the Health Plan based upon a determination that it was not medically necessary.The patient has excessive daytime somnolence likely related to a primarily sleep disorder and sedating medications including OxyContin, Neurontin, and Topamax. She has been taking Provigil for several months, and the medication has afforded her substantial improvement in her ability to manage her pain, to maintain her cognitive functioning, and to perform effectively at work.  While Provigil is not FDA approved for medication related EDS, it is widely used in this clinical setting by psychiatrists, neurologists, and pain management specialists.  Based on the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female with a history of fen-phenormin and Redux use who was diagnosed with asymptomatic mild to moderate aortic insufficiency. The patient was seen by her network cardiologist who recommended a repeat echocardiogram in one year, then yearly. The patient saw an out-of-network provider who recommended three follow-up visits and an echocardiogram every year or every other year to follow-up with the severity of aortic insufficiency. The patient has requested authorization and coverage for follow-up care from the out-of-network cardiologist. The Health Plan has denied the request.This patient falls within the classification of asymptomatic mild to moderate aortic regurgitation with normal left ventricle chamber size. In concordance with ACC/AHA guidelines for the management of patients with valvular heart disease, yearly echocardiograms for the reevaluation of asymptomatic patients with mild to moderate aortic regurgitation, stable physical signs, and normal or near normal left ventricle chamber size is a Class III indication. Thus, there is evidence and/or general agreement that routine surveillance echocardiograms are not useful or effective. Routine clinical follow-up to assess for changes in physical signs or symptoms development however is indicated; the timing and intervals routinely vary among practice patterns to monitor for changing physical signs and or symptoms change. Both cardiologists appear to address a follow-up visit, and though it is spelled out more clearly in the out-of-network cardiologist recommendations, there is no significant difference in the two clinical follow-up approaches to this patient.Therefore, I have determined that the patients request for follow-up care with an out-of-network cardiologist is not medically necessary since the portion of the services that differ are not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guidelines, this patient does not meet the criteria for IOP services. The patient presented with no risk of harm (score 1) due to a lack of current suicidal ideation, aggression or self-harm behaviors. The progress notes do not indicate that the patient has demonstrated any suicidal or homicidal ideation or psychosis. He presented with some anxiety and depression symptoms in regards to his eating disorder but most of the time he has been noted to have a euthymic mood. The patient has demonstrated mild functional impairment (score 2) given his overall ability to function and participate in treatment. The patient presented with minor comorbidities (score 2) due to the presence of obesity, overall medical stability, and no substance use issues. There was no indication of significant unstable or uncontrolled medical issues. He had not engaged in any substance abuse according to the records. The patients recovery environment is described as mildly stressful (score 2) considering his stable living environment and his recovery environment is supportive (score 2). The patients treatment response has been significant (score 2). The provider noted that the patient has been open in treatment and receptive to feedback from his providers and group members during group therapy. The providers noted that the patients mood has stabilized and there is a lack of any acute behavioral health symptoms. However, the patient has continued to gain weight. The patient has been constructive in IOP (score 2) due to good cooperation in treatment. This gives the patients presentation a composite score of 13, which score correlates with low intensity community based services. All told, the IOP services rendered were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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

A 22-year-old female enrollee has requested for residential treatment services for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the peer reviewed medical literature regarding residential treatment options for patients with anorexia nervosa and bulimia nervosa note that such programs are becoming increasingly more common. The studies also reveal that a wide variety of techniques and methods are employed in the treatment of patients with eating disorders within such residential treatment programs. The American Psychiatric Association (APA) has provided level of care guidelines for patients with eating disorders. These guidelines take into consideration 10 separate factors affecting eating disordered patients and cross reference these with a 5 level system to assist practitioners with assessment, recommendations, and planning in determining the clinically appropriate levels of care. All told, the medical necessity is currently supported for the RTC services.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Supartz injections for the right knee. Findings:  Two of the three physician reviewers found that the peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and has been showed to be more effective than corticosteroid injections. In this case, the patient presents with recurrent right knee pain, swelling, and giving way. Clinical examination findings were consistent with radiographic evidence of moderate osteoarthritis. He has failed to respond adequately to other conservative treatment, including nonsteroidal anti-inflammatory drugs, opioid medication, and corticosteroid injection. Prior hyaluronan acid injections have provided excellent pain relief for at least six months. Therefore, the requested Supartz injections for the right knee are likely to be superior over other available treatment options. 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.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: Upheld

A 29-year-old female enrollee has requested labiaplasty for the treatment of her hyperplastic labia.  Findings:  The physician reviewer found that there were no records submitted identifying the course of the patients labial excess, particularly when it developed and efforts toward symptom management. There does not appear to be a degree of functional impairment sufficient to justify surgical intervention. It is also not entirely clear whether the patients pain with exercise can be fully attributed to enlarged labia. A literature search over the past 10 years revealed only two peer-reviewed articles on labiaplasty, neither of which discusses the medical necessity of the procedure. As no medical basis for this surgery has been established in the peer-reviewed literature, the procedure should reside in the realm of cosmetic surgery until there is valid evidence to the contrary.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female has requested coverage for past sub-acute substance abuse residential treatment center services for treatment of alcohol dependence.  Findings:  The physician reviewer found that due to multiple factors and unique considerations, determination of the appropriate level of care for patients with addictive disorders is a challenging endeavor.  Per the American Psychiatric Association, residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack substance-free social supports or sufficient motivation to remain abstinent in an ambulatory setting.  In this patients case, she had failed lower levels of care.  Her alcohol consumption was dominating functionality, and her social setting was unable to support her sobriety.  The current medical evidence supports the services at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested partial hospitalization program (PHP) services for medical treatment of her substance abuse and depression. Findings:  The physician reviewer found thatThe American Psychiatric Association (APA) treatment guidelines recommend 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. Thus, continued admission to PHP is appropriate to treat her condition, consistent with standards of good medical practice in the United States, could not be managed effectively at a lower level of care and is thus medically necessary.