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

The patient is a 50-year-old female who underwent several surgical procedures at one sitting. In question is the medical necessity of liposuction of the abdomen and flanks, which was performed at the same time as her breast implant removal, capsulectomy, mastopexy, and abdominal scar revision. The Health Plan denied reimbursement for the liposuction based upon a determination that it was not medically necessary.Received and reviewed were the operative notes, history and physical examination, a color photocopy of a photograph of the patient and a note from the plastic surgeon in support of the scar revision procedure. Upon review of these documents, I find no evidence of medical necessity for the liposuction of the abdomen and flanks. The procedure at issue was cosmetic in nature and not medically warranted. Therefore, I have determined the procedure 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for facial feminization surgeries (brow lift, jaw reduction/contouring, lip reduction and rhinoplasty) for treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found based on the medical documentation provided for this review, a portion of the services at issue is medically necessary and reconstructive in nature. The medical literature supports facial feminization surgery, which may include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. This patient has documented gender dysphoria. However, the photographs provided show evidence of a relatively normal forehead without evidence of an abnormal gender appearance.  The brows are in a relatively normal position without significant ptosis or an abnormal gender appearance. The nose and lips are relatively normal, without an abnormal gender appearance. The documentation provided, including a review of the photographs, do not support the medical necessity for the brow lift, lip reduction and rhinoplasty. These findings are relatively gender neutral and should have been considered treatment of relatively normal structures in this patients case. On the other hand, the patient showed evidence of a significantly masculine appearance of the lower face, specifically, the chin and jaw.  The chin and lower face demonstrated a significantly widened masculine appearance for a female. As such, this should have been considered outside the normal structures typical for a female. Therefore, jaw reduction/contouring was medically necessary for treatment of this patients gender dysphoria. However, brow lift, lip reduction and rhinoplasty were not medically necessary. Final Result: The reviewer determined that a portion of the services at issue was medically necessary and was reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested jaw realignment surgery (maxillomandibular osteotomy) for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that the literature provides ample treatment options including surgical and nonsurgical approaches for patients with OSA. Although this patient is symptomatic with daytime fatigue and has hypertension, there is no recent objective documentation of the severity of his problem. In the year specified, his study showed the presence of mild OSA with an AHI of 7. A current polysomnography would be helpful in determining outcome. Multilevel surgery has become the standard of surgical care in well selected patients with OSA. However, this patients records do not support the medical necessity of the requested surgical intervention. All told, the requested jaw realignment surgery (maxillomandibular osteotomy) is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator (Inspire procedure). Findings:  The physician reviewer found that the Inspire hypoglossal nerve stimulator is U.S. Food and Drug Administration (FDA) approved, and recognized by the American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) and the International Sleep Surgery Society (ISSS). With regard to efficacy, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of symptoms in patients with OSA (Woodson, et al). The authors noted that upper airway stimulation addresses the twin goals of improving anatomic and neuromuscular pathology. Further, the authors concluded that hypoglossal nerve stimulator can benefit patients with OSA who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index (BMI) of less than 32 kg/m2. This patient is intolerant to CPAP and has a BMI of 31 kg/m2, an AHI of 45, and nonconcentric airway collapse. Thus, the implantation of hypoglossal nerve stimulator (Inspire procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the implantation of hypoglossal nerve stimulator (Inspire procedure) 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 implantation of hypoglossal nerve stimulator (Inspire procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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

A 58-year-old female enrollee has requested artificial disk replacement for the treatment of her degenerative lumbar disc disease. Findings:  Three physician reviewers found that the proposed procedure is in fact experimental. Current data for single-level disc replacement demonstrates that the majority of the procedures may be  successful in the short term, however there is not enough long-term, follow-up data to clearly establish efficacy. This is particularly true for multi-level disc replacement. Additionally, the potential long-term complications of total disc replacement have not been fully explored and there is not yet adequate data on the durability of this approach.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for Abraxane for treatment of her metastatic melanoma.   Findings:  Two physician reviewers found that Abraxane is the albumin-bound form of paclitaxel and is being studied for the treatment of a variety of cancer types. There is a paucity of information regarding its use in the treatment of metastatic melanoma. Homsi and colleagues conducted a phase II trial wherein 30 patients with metastatic melanoma were treated with Abraxane. Three of the patients experienced partial responses, suggesting a similar efficacy to conventional dacarbazine therapy. The authors noted the need for further studies to support its use. Hersh and colleagues conducted a phase II trial wherein 74 patients with metastatic melanoma were treated with Abraxane. Their responses were thought to be equivalent to current standard chemotherapy regimens. These studies are the only studies conducted that focused exclusively on the use of Abraxane therapy alone, not in combination with other drugs. The results of these studies are not sufficient to support the conclusion that Abraxane therapy is likely to be superior to other conventional therapies in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan (Orthovisc) injections in the left knee for treatment of the enrollees knee pain. Findings: The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this case, it is documented the patient has been treated with physical therapy, braces, Norco, and underwent corticosteroid injections. Moreover, the patient is not a reasonable candidate for repeat corticosteroid injections so close to the time of planned revision right knee arthroplasty which might increase risk of periprosthetic joint infection. Previously, the patient has experienced success with viscosupplementation. For these reasons, the requested hyaluronan (Orthovisc) injections in the left knee is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 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

A 60-year-old male enrollee has requested authorization and coverage for the medication Tarceva for treatment of his metastatic prostate cancer.  Findings:  The physician reviewer found that Tarceva is an oral chemotherapeutic medication used mainly for pancreatic or non-small cell lung cancer; it is not used extensively for prostate cancer. Tarceva is however, a tyrosine kinase inhibitor and an inhibitor of human epidermal growth factor receptor type 1/epidermal growth factor receptor (HER1/EGFR). The immunochemical testing of the biopsy specimen was very positive for EGFR. The providers rational for choosing Tarceva is well considered and well documented. This medication appears to be an appropriate chemotherapeutic agent at his juncture in the patients treatment for prostate cancer.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested residential treatment facility services for treatment of her anorexia nervosa. Findings:  The physician reviewer found that the submitted clinical records demonstrates that this patient had failed prior treatment at inpatient and residential treatment levels of care. She left treatment in the past against medical advice and also insisted that her psychiatric medications be discontinued despite her psychiatrist recommending against this. Her insight and judgment were very poor when she entered treatment. The treatment center and her family both indicate that her insight and judgment are vastly improved after her stay at the residential treatment center. Her functioning has dramatically improved as a result of the services at issue. This patient was admitted to an inpatient level of care numerous times in the past secondary to medical complications of her anorexia nervosa. The medical literature on the necessity for inpatient weight restoration is contradictory, as is the literature on appropriate level of care for those who are diagnosed with anorexia nervosa. While much of the literature is variable, the records provided demonstrate that this patient did benefit from her stay at the residential treatment center and had failed several other treatments in the past.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance guided focused ultrasound (MRgFUS) ablation of uterine leiomyomata (CPT code 0071T). There are multiple treatment options for the management of a multi-fibroid symptomatic uterus. If a patient opts for uterine-sparing interventions, then surgical options include laparoscopic, hysteroscopic, or abdominal myomectomy procedures versus less invasive options including MRgFUS. As noted in the medical literature, MRgFUS utilizes high-intensity ultrasound energy to induce coagulative necrosis of fibroids. MRgFUS results have been reported to reduce myoma volume by approximately 37-40% (Gorny, et al.). The MRI provides real-time visualization and thermal monitoring to optimize tissue destruction with optimization of safety. There are a number of factors that may impact effectiveness of treatment including size, vascularity, and heterogeneity of the fibroids. Ideal treatment candidates have three or fewer fibroids measuring less than 10 cm in maximal dimension, homogenous and dark on T2-weighted images, and well-vascularized without calcification (Gorny, et al.). Based on this guideline, this patient met the criteria for MRgFUS. She presented with multiple fibroids, with the largest measuring about 5 cm. MRgFUS is an accepted treatment option in this clinical setting. Accordingly, the MRgFUS ablation of uterine leiomyomata (CPT code 0071T) was likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the MRgFUS ablation of uterine leiomyomata (CPT code 0071T) was likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 obstetrics and gynecology 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 53-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the brain for evaluation of his prolactinoma.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. A prolactinoma, the most common type of pituitary tumor, is a benign tumor of the pituitary gland that produces an excessive amount of a hormone called prolactin. Symptoms of a prolactinoma may be due to either excessive blood levels or prolactin or by pressure of the tumor on surrounding tissues. In men, the excessive prolactin levels can lead to secondary hypogonadism (Baltzar et al.). Pressure symptoms include headaches, visual disturbances, nausea, and vomiting. A prolactinoma is diagnosed based upon an elevated blood level of prolactin and evidence of a mass in the pituitary gland, as seen on an MRI scan. MRI is the most sensitive imaging test for detecting and measuring prolactinomas. Prolactin levels and radiologic imaging with MRI scanning should be periodically performed to monitor for response of the prolactinoma to medical therapy and to assess for possible change in size of the tumor (Schlechte). In this case, due to the patients history of a prolactinoma it is important that he be followed routinely with imaging studies, such as an MRI, to monitor response to medical therapy; his onset of headaches further necessitated close monitoring of the tumor and thus a repeat MRI was appropriate and indicated. Given the reasons provided above, the MRI of the brain performed on the date in question was medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization for treatment of the enrollee who has a history of hemorrhoids. Findings:  2/3 of the physician reviewers found that THD is a technique used by colorectal surgeons as a treatment option for hemorrhoids. Multiple studies in support of THD have been recently published. For example, a recent systematic review and meta-analysis was published regarding the clinical outcomes and effectiveness of surgical treatments for hemorrhoids.  The review included 98 studies with 11 treatments for hemorrhoids and 7,827 patients.  The authors concluded that THD was associated with less postoperative bleeding and therefore, less emergency reoperations as well as decreased postoperative complications, shorter operative time, and decreased pain.  The authors concluded that the low cost of THD, low complication rate, shorter operating time and decreased levels of postoperative pain, but higher recurrence rate, may suggest THD as a safe, quick and easy initial surgical option.   In another study the authors concluded that THD is a safe and effective treatment of hemorrhoid disease. As such, the current medical evidence supports the efficacy of this treatment option for the treatment of hemorrhoids in patients who have exhausted conventional nonsurgical options. All told, Doppler-guided transanal hemorrhoidal dearterialization performed was likely to have been of greater benefit than other treatment modalities for the treatment of this patients hemorrhoidal disease.  Final Result: 2/3 of the 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: Physician reviewer number one is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number two is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number three is board certified in surgery with sub-specialty certification in colon and rectal surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested coverage for past hospital care for treatment of his bladder tumor, urinary tract infection and gastritis.  Findings:  The physician reviewer found that in this patients case, hospital care provided on the dates under review was not medically indicated.  During these dates of service, the patient could have been safely and effectively managed in an outpatient setting.  This patient presented with hematuria and was afebrile.  Urinary tract infection was suspected, although culture proved negative.  He also reported vague abdominal discomfort, without urinary retention.  In this clinical scenario, outpatient evaluation would have been appropriate.  Outpatient antibiotics and monitoring status of fever and abdominal pain was medically appropriate in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested eating disorder partial hospitalization program (PHP) services for treatment of his bulimia nervosa.  Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, in determining a patients initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. The records document that this patient has been diagnosed with bulimia nervosa and struggled with symptoms of anxiety and eating disordered behaviors including restricting food, binging, purging, negative body image, and body checking daily, which resulted in a 2.8 pound weight loss in a week prior to admission. He continued to struggle with substance abuse issues which resulted in relapses and had an overdose attempt during his course of treatment. On admission, he was restricting 15% of his meal plan daily, or 357 calories, and on discharge was able to reach 100% of meal plan compliance on most days, but still restricting 25% of his meal plan on the weekends, which is about 595 calories per day, and had strong urges to exercise. All told, the PHP services rendered at the facility indicated through the time period specified were medically necessary as the patient was experiencing mood lability, needed substance use monitoring, had the potential for self-harm.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested for growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the lack of delayed bone age and thus his low adult height prediction, he is clearly an appropriate candidate GH therapy. He has a diagnosis of idiopathic short stature and fulfils the criteria of the FDA ruling of 2003 for treatment with GH therapy. GH therapy is clinically indicated in this instance to promote increased growth velocity and maximize final adult height.