Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294). Accelerated partial breast irradiation (APBI) may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy (IORT). IORT to perform APBI is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria per current National Comprehensive Cancer Network (NCCN) guidelines. Researchers reported that at four-year follow-up, local control rates between IORT and external beam whole breast radiotherapy were largely equivalent. A study concluded that, Important radiation-related quality of life parameters after IORT were superior to external beam radiation therapy. Per the authors, toxicity may also be slightly improved with IORT. This patient meets ABPI criteria set by the American Society of Breast Surgeons (ASBS), given her age and the presence of a tumor measuring less than 3 cm. All told, the requested IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) 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 IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology 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: The patient has requested reimbursement for the the gene test. Mutations associated with the clinical diagnosis of NF1 disrupt the function of the NF1 gene. Due to the large size of the gene and the heterogeneity of mutations, molecular testing includes sequencing of all of the coding exons as well as tests for deletions or rearrangements of a portion or the entire gene. Molecular testing has been reported to find the causative DNA mutation in approximately 95% of patients who carry the clinical diagnosis of NF1. As there are several conditions that can present with features similar to NF1, but require different strategies and have different recurrence risks, a diagnosis is critical. If the NF1 mutation testing is negative, then the provider may perform mutation testing to evaluate for Legius syndrome. If both are negative, then the provider may recommend genetic testing of the four mismatch repair genes or Noonan syndrome. Medical literature supports molecular testing of the NF1 gene in this case as the best evidence-based practice. Therefore, the gene test was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in pediatrics with subspecialty certification in genetics and is actively practicing. One Reviewer is board certified in pediatrics with subspecialty certification in genetics and is actively practicing.  One Reviewer is board certified in pediatrics with subspecialty certification in genetics 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: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for continued occupational therapy for treatment of her condition. Findings:  The physician reviewer found that occupational therapy is the most appropriate intervention for patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested an out-of-network consultation, Botox injections and MR neurography for treatment of her pudendal nerve entrapment. Findings:  The physician reviewer found that in determining medical necessity for the out-of-network consultation, consideration must be given to the fact that the patient had to wait six months for an appointment with the in-network pain specialist, during which time she was in significant pain. This constituted an unreasonably long delay and, as such, the consultation at issue was medically necessary. Furthermore, the use of magnetic resonance is an appropriate tool in the diagnosis of sacral plexi. The American Academy of Radiology endorses its use as highly appropriate for this indication in their practice guidelines. Therefore, the use of MR neurography was clinically indicated and medically necessary for proper evaluation of the patient.With regard to the Botox injections at issue, although trigger point injections have been used successfully to treat pudendal neuropathies, the efficacy of Botox in this clinical setting remains unproven. Thus, given the absence of significant trials demonstrating the benefit of Botox for patients such as this patient, its use in this case was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services for treatment of the enrollees alcohol use disorder. Findings:  The physician reviewer found that based on the records provided for review, this patient appeared to have post-acute withdrawal symptoms and he was on Campral. However, he was not a danger to himself or others, he was medically stable as his hypertension was controlled on medications, and the patients elevated creatinine did not require 24-hour monitoring. Further, the patient was not seen by a physician after the initial evaluation, there are no nursing notes, there is no treatment plan, and there are only American Society of Addiction Medicine (ASAM) criteria evaluations. These are not considered treatment plans with updates which are individualized for the patients particular needs. 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 with sub-specialty certification 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: Overturned

The patient is a 41-year-old woman with breast hypertrophy. She has photographic evidence of macromastia and the typical symptoms associated with severe breast hypertrophy including complaints of shoulder, neck, and back pain, bra strap grooving and intertrigo. She has requested authorization for bilateral breast reduction surgery. The Health Plan has denied her request on the basis that the requested procedure is not medically necessary for treatment of her condition.Breast reduction surgery is medically necessary for this patient. She has documented breast hypertrophy and her complaints are typical for symptomatic macromastia. The constellation of symptoms in the context of breast hypertrophy is diagnostic for symptomatic macromastia, and additional workup is not required. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic macromastia. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. The value of breast reduction in improving or correcting symptoms of macromastia is well documented in peer-reviewed scientific studies. As noted by Kerrigan, et. al., weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.  Although recent literature questions the correlation between volume of tissue resected and symptom resolution, studies have been performed to try to distinguish cosmetic from reconstructive breast surgery based on the volume of reduction.  The scientific validity of these studies is quite weak when compared to the more current literature.  Nonetheless, according to Schnur, the volume of reduction can be used to distinguish cosmetic from functional breast reduction surgery. Using the Schnur criteria, the anticipated total volume of resection for this patients surgery to be considered functional and medically necessary is approximately 310 grams per breast (body surface area of 1.60). Seitchik has also published criteria for insurance coverage, and according to his formula, the anticipated volume of this patients reduction is above coverage requirements. The planned reduction of 800 grams per breast is more than twice the amount that the literature suggests will differentiate a cosmetic from a functional reduction.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary The parent of an enrolleee has requested reimbursement for psychiatric residential treatment center (RTC) services provided. Findings:  The physician reviewer found that Review of the submitted documentation indicates the patient was approved for admission to a RTC on transfer from another facility, and at the recommendation of the previous facility. The patient continued to meet criteria for continued stay in a RTC as the enrollee was expected to have continued weekly psychiatric evaluations, was making progress toward established goals, and was being cooperative. However, the patient  had demonstrated significant progress toward goals of emotional regulation and relationships. The goal of improved trust within the family could better be met with intensive outpatient program (IOP) treatment, and multisystem therapy delivered in a less restrictive environment. The enrollee had begun to lose trust and confidence in the staff, became uncooperative with treatment, and stated that the patient believed that they would would always be in an inpatient facility. For these reasons, the medical records demonstrate that the psychiatric RTC services provided  were medically necessary for treatment of this patients behavioral condition but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue were 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 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: Upheld

The patient is a 39-year-old female with a history of morbid obesity and is status post gastric bypass in 2000. She also experiences depression and anxiety. The patient has been experiencing upper arm pain since she underwent debulking surgery following her weight loss. The patient has not responded to medications, sympathetic block, and physical therapy. She is taking methadone 5mg every 8 hours and is seeking an increase in her prescription to 20mg twice daily. The Health Plan has denied this request indicating the requested prescription increase is not medically necessary.Upon review of the medical records provided I have determined the requested prescription increase is not medically necessary for treatment of the patients medical condition. The alternative option set forth by the Health Plan is more clinically prudent as isolated treatment of the patients pain without multidisciplinary interventions as offered in a chronic pain treatment center has failed her. The patient is likely to obtain longer lasting pain relief from participation in a pain management program. Therefore, I have determined that the requested prescription increase is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for DDAVP desmopressin acetate injections. There is sufficient support for the requested medication in this clinical setting. Central diabetes insipidus is a common sequela of cranial surgery and radiation therapy. DDAVP is a cornerstone of therapy. Per the submitted documentation, this patient has not benefitted from the oral form of this medication. He has been well-maintained on the injectable form of this medication. In this patients case, the records support the use of the injectable form of this medication, as it has been demonstrated to be effective. Therefore, DDAVP desmopressin acetate injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 25-year-old female enrollee requested diagnostic testing for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  An appropriate gastroenterology evaluation was conducted, and a diagnosis of ulcerative colitis was made.  The medical documentation indicates that a thorough laboratory work-up and physical examination were unrevealing for any other diagnosis than what was rendered and treated.  The requested additional diagnostic testing is not expected to alter the patients treatment or outcome.  All told, the requested additional diagnostic testing is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-eight year-old obese female with comorbid conditions is requesting authorization of a laparoscopic gastric banding procedure.  Reviewers Findings:  The reviewing physician found that the clinical record indicates the patient clearly meets the Health Plans criteria for authorization of bariatric surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Estrogel 1.25 gram/actuation 0.06% gel. Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.The medical evidence supports the requested medication in this clinical setting. Per the current literature, systemic estrogen replacement therapy is the most effective treatment for menopausal symptoms. Estrogel is effective for the treatment of postmenopausal vasomotor symptoms. The enrollee has tried other formulations of estrogen/hormone replacement therapy, but these treatments have been ineffective. Estrogel has been approved by the U.S. Food and Drug Administration for the treatment of postmenopausal symptoms. Therefore, Estrogel 25 gram/actuation 0.06% gel is medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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: This is a patient with right knee osteoarthritis (OA), cardiac disease (coronary artery disease, congestive heart failure and cardiomyopathy), and gastric reflux. The patient cannot tolerate anti-inflammatory medications due to his cardiac disease. At issue is whether the requested Orthovisc Injections in the right knee (J7321) are medically necessary to treat the enrollees medical condition. The patient received some benefit from PT and reports currently riding a bicycle up to 30 miles a day. The literature recommendations for the use of viscosupplementation (Orthovisc) have recently changed. Previously, scientific literature had recommended viscosupplementation for the treatment of OA if all other conservative treatment failed prior to surgery. However, that is no longer the current clinical practice guidelines (CPG) based on the evidence-based research, which no longer recommends using viscosupplementation for symptomatic OA of the knee.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested Synvisc One injection to the knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining treatment options are limited. In this patients case, the medical records document a history of osteoarthritis with pain and swelling and prior corticosteroid injections were not effective, but the patient reported good relief from prior viscosupplementation. Furthermore, the patients remaining treatment options were limited with the alternative being a total knee arthroplasty for moderate degenerative changes. For these reasons, the Synvisc One injection in the knee was medically necessary for 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 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

The enrollees parent is requesting authorization and coverage for male chest reconstruction. The enrollee is transgender male with gender dysphoria. He began taking testosterone and has helped lessen his gender dysphoria and anxiety, but he still has anxiety about his chest and binds it daily. The enrollees counselor reports the enrollee has participated in individual counseling. The enrollee is confident in his gender identity and participates in all domains of his life as a male. The counselor reports he meets all criteria for gender dysphoria. There are no psychiatric contraindications to chest masculinization surgery. He is intelligent and thoughtful and has demonstrated the ability to make informed decisions about his care. He has the support of his parents to consent for h0-is care. This surgery will positively impact his persistent gender dysphoria related to his chest, provide him with greater gender congruency and add great quality to his life.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a five-year-old male diagnosed with autism/pervasive developmental disorder with an associate mixed receptive and expressive language delay. The patient has been receiving speech therapy services since May 2003. Goals established included improvement in pragmatic language, increase in expressive vocabulary, combining word to phrases and following directions. The Health Plan has denied coverage for speech therapy from January 2005 onward on the basis that speech therapy is not medically necessary for this patient.In reviewing the goals as outlined in May 2003 and comparing them with the summary dated May 2005 there is sufficient evidence the patient has been making gains. These gains have been slow, but the goals and objectives are appropriate and he has achieved the goals. Given that the patients therapist provided appropriate goals and there have been documented gains in these goals, I have determined that continued speech therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should continue to receive speech therapy services with re-evaluation in six months.