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 liposuction of the trunk (abdomen and flanks, outer thighs). The World Professional Association for Transgender Health (WPATH) Standards of Care discussed the complex nature of aesthetic versus reconstructive aspects of non-genital surgeries. The WPATH noted that some procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. In this case, the documentation provided by this patient and his treating providers establishes the diagnosis of gender dysphoria. The providers letters state that the patient has gender dysphoria related to his body and the shape of his trunk, which has feminine fat distribution and causes psychological distress. The provider noted that the patients treatment plan includes bilateral mastectomies and liposuction. The planned bilateral mastectomies will directly address the patients distress related to gender dysphoria and is consistent with the WPATH Standards of Care. A 2019 study suggests that body fat in transgender men is positively correlated with testosterone dose. A 2018 study indicates that the use of testosterone improves the gynecoid appearance of fat distribution. In this case, the patient is noted to continue to have gender dysphoria despite high dose testosterone therapy. Given this continued distress, it is reasonable to consider liposuction as adjunct management of the gynecoid fat distribution. Therefore, liposuction of the trunk (abdomen and flanks, outer thighs) 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 psychiatry with expertise in transgender 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 conditio
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. Current medical literature does not support the use of the DecisionDx-Melanoma test for the staging or treatment of melanoma, and there is a lack of evidence regarding its clinical utility, reliability, or improved outcomes for melanoma patients. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of cutaneous melanoma do not recommend the use of the service at issue. The American Academy of Dermatology guidelines of care for the management of thin melanomas, as in this case, do not report any practical benefit from the use of the DecisionDx-Melanoma testing. In this case, the results from the testing would not change the outcome or treatment for this patient, who would be required to have a wide local excision and then periodic follow-up skin examinations. Therefore, DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 reviewers 1, 2, and 3 are board certified in dermatology 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: Overturned

A 59-year-old male enrollee requested Subutex (buprenorphine) for medical treatment of his chronic pain syndrome.  Findings:  The physician reviewer found that the medical records provided for review indicate the patient has a chronic pain condition with associated postural hypotension and a reported history of pain control with oxycodone in the past. The provider reports that the patient was switched to Subutex and reduced overall opioid use while maintaining good pain control and not experiencing any adverse events. As the medical records support the patient has maintained good pain control for chronic pain condition and markedly reduced previous opioid use with Subutex, the requested medication is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301-450 pounds (K0825). The records provided for review indicate that this patient has multiple chronic health conditions. The patients provider has recommended a power wheelchair, with a primary indication of atrial fibrillation. The atrial fibrillation has been noted to be paroxysmal. The patient has been appropriately treated with anticoagulation for cardioembolic stroke prophylaxis, as well as multiple pharmacotherapeutic agents and adjustments for rate control (January, et al.). However, the records do not establish that the patient requires a power mobility device to accomplish the mobility-related activities of daily living. Specifically, the patient reports symptoms with too much walking, but there is no documentation that this symptomatology has been verified to be rapid atrial fibrillation, such as through ambulatory event monitoring. Current recommendations for atrial fibrillation management include aggressive treatment of modifiable risk factors for disease progression, including obstructive sleep apnea, obesity, hyperlipidemia, and physical inactivity (Middeldorp, et al.). Use of a power mobility device in lieu of ambulation is expected to exacerbate the patients obesity and comorbid health conditions. Given these findings, the requested power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301-450 pounds (K0825) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Xeljanz 5 mg tablets. The treatment for small vessel vasculitis includes initial immunosuppressive therapy and maintenance. In this patients case, there is no evidence of severe organ involvement and the patient appears to be in the maintenance phase. She has been treated with prednisone and rituximab as well as CellCept monotherapy and in combination with a prednisone burst. She has responded well to treatment with Xeljanz, which is a Janus kinase (JAK) inhibitor. However, there are limited studies demonstrating the safety and effectiveness of JAK inhibitors for the treatment of vasculitis. The current guidelines support treatment with azathioprine, rituximab, or methotrexate in this clinical setting. This patients records do not report that she has exhausted treatment or has a contraindication to treatment with azathioprine or methotrexate. Therefore, the requested Xeljanz 5 mg tablets are 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 internal medicine with subspecialty certifications in allergy and immunology and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Myriad Genetic Laboratories test. BRCA testing guidelines recommend BRCA testing for this patient with two close relatives with ovarian cancer. However, the entire MyRisk panel includes BRCA testing plus analysis for another 26 genes. Though many of the other gene mutations are of interest and are being studied, there is a lack of data that the findings from this testing is significant to be the basis for any clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from major organizations. With two young family members with ovarian cancer, the BRCA testing was appropriate in this case. However, there is a lack of data supporting the clinical utility of the remainder of the genetic testing.Thus, the BRCA portions of the Myriad Genetic Laboratories test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy and the remainder of the Myriad Genetic Laboratories test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the BRCA portions of the MyRisk genetic panel was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy and the remainder of the MyRisk panel 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 BRCA portions of the MyRisk genetic panel was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy and the remainder of the MyRisk panel was not 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 internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that he American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Regarding the six CALOCUS dimensions, the patient had no risk of harm; the patient was not actively suicidal or passively suicidal (score = 2). Regarding functional status, the patient had some issues with level of functioning due to mental illness and relational issues, but overall, showed appropriate daily functioning while in treatment and indicated that prior school functioning was good (score = 2). There were no comorbidities noted (score = 1). The patient had a mild level of stress. He was noted to have interpersonal conflict with his father and a good relationship with his mother, peers and siblings (score = 2), and the patients parents were involved in treatment on a regular basis (score = 2). The patient had a good response to a short period in the RTC, with minimal continued signs or symptoms of anxiety and depression (score = 3). He participated in therapy actively for a majority of the time but was also uncooperative on occasion (score = 2-3) and his parents worked actively and constructively with clinicians on a regular basis (score = 2). This gives the patients presentation a composite score is 16-17, which corresponds with an Intensive Outpatient Services level of care. This score is judged by the acuity of the patients symptoms and environment during the period at issue. Accordingly, the Residential Treatment Center (RTC) services at issue were 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 psychiatry with a subspecialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Abilify Maintena 400 mg injections. Abilify Maintena has been US Food and Drug Administration (FDA) approved for the treatment of schizophrenia and for the maintenance treatment of Bipolar I disorder in adults. However, Abilify Maintena has not been FDA approved for treatment of patients with OCD or depression. This patients diagnoses includes OCD and moderate to severe depression. Based on the documentation, the patient does not meet the criteria for schizoaffective disorder. As this patient does not meet the criteria for diagnosis of schizophrenia or Bipolar I disorder, there is no clinically recognized indication for the requested medication. Thus, the requested Abilify Maintena 400 mg injections are not supported as medically necessary for treatment of this patients OCD and depression. 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 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: An enrollee has requested authorization and coverage for custom orthotics for treatment of the enrollees foot pain.  Findings: The physician reviewer has found that as noted in the medical literature, custom orthotics are supported as medically necessary after a patient has failed treatment with strapping and over the counter type foot supports. Review of the documentation provided does not support demonstrate that the patient has failed treatment with strapping and over the counter type foot supports. Thus, the requested custom foot orthotics are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 fifty-nine year-old male with a history of spinal muscular atrophy is requesting authorization for a Pro Bed.Reviewers Findings:  The reviewing physician found that the information provided is not sufficient to make a determination that this bed will safely meet the patients need or that it will be effective in repositioning the patient as needed during the night.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a fourteen year-old obese female with comorbidities including arthritis, psychological issues, and hyperinsulinemia is requesting authorization and coverage for a referral to an endocrinologist.  Reviewers Findings:  The reviewing physician found that due to the patients lack of response to medication and attempted dietary and exercise activity intervention, it is essential that the patient be closely monitored by experts in caring for adolescents with morbid obesity and associated comorbidities.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 180 pills of Percocet 10/325 mg for a 30 day period. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non palliative settings. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication quantity and several recent requirements for opioid prescribing have not been documented. In this case, there is no clear objective goals and no medical evidence based rationale provided by the provider for the requested quantity of Percocet. Additionally, the records do not demonstrate that other non pharmacological forms of treatment have been performed. There is no mention of completion of behavior therapy documented despite much research to support its use.  For all these reasons, 180 pills of Percocet for a 30 day period is not medically necessary for treatment of the patients medical condition. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Synvisc-One injection in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate 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 options are limited. The patient has tried and failed other conservative treatments. Frequent corticosteroid injections are not helping, with the alternative being bilateral total knee arthroplasties. Thus, a Synvisc-One injection in both knees is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested services 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: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee has requested the Provent SR nasal device for treatment of his obstructive sleep apnea. Findings:  Two physician reviewers found that Provent SR is an FDA approved device for patients with obstructive sleep apnea. Alternative therapies, such as a dental appliance and pillar procedure are also possibly effective, but would require additional sleep studies to confirm. Additionally, the patients provider has indicated that this patient is not a surgical candidate. The submitted clinical evidence demonstrates that this patient has failed a trial with a standard CPAP device and his sleep study results indicate a positive response with the Provent SR device. Therefore, this device is likely to be more beneficial for treatment of this patients obstructive sleep apnea than the available standard therapy.