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

The patient has requested reimbursement for facial hair removal services (electrolysis epilation). Facial hair removal is a common treatment for gender dysphoria that helps with social functioning. The World Professional Association for Transgender Health (WPATH) lists hair removal, through electrolysis, laser treatment, or waxing, as an option to help alleviate gender dysphoria. In this case, the patients providers supported the medical necessity of facial hair removal services to treat the patients gender dysphoria. Therefore, facial hair removal services (electrolysis epilation) were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, the requested medication is not medically necessary for treatment of the patients medical condition. A study noted that short and long acting opioids have been found to be effective for chronic non-cancer pain. The authors also noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In this case, the patient has chronic neck and back pain that has persisted for many years. She has been treated with a multitude of therapies in the past for her pain. Although she reports that Norco has been effective for her pain, her provider does not recommend this medication due to her history of alcohol abuse. The Health Plans recommendation for a referral to pain management, physical therapy and behavioral health management is medically appropriate for this patient. Therefore, based on current medical literature and in consideration of the presented clinical records, the request for Norco has not been established as medically necessary for 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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

A 38-year-old female enrollee has requested for physical therapy (PT) for treatment of her knee and back pain. Findings:  The physician reviewer found that the records show some limited improvement in the patients tolerance of PROM, which was not clearly documented or quantified. It does not appear there were any significant changes in the patients symptoms, range of motion, or exercise program.The patient could have reasonably continued with the exercise program at home. There is no documentation that the modalities used provided any temporary or permanent reduction in the patients pain or facilitated the patients exercise program.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested for transcranial magnetic stimulation therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that the American Psychiatric Association has indicated that transcranial magnetic stimulation therapy is an appropriate acute phase treatment option for patients who do not adequately respond to medication therapy.  The patient has failed to achieve remission despite multiple medication trials, including augmentation with Abilify and Geodon, and thyroid augmentation.  In this patients case, there is a lack of available treatment options.  Therefore, transcranial magnetic stimulation therapy is likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization coverage for eyelid surgery (CPT 67908  repair blepharoplasty conjunctive-tarso-mullers muscle-levator resection (1 unit) and CPT 15823  blepharoplasty upper eyelid with excessive skin (1 unit)) for treatment of the enrollees bilateral dermatochalasis and myogenic ptosis. Findings:  The physician reviewer found that upper eyelid ptosis can lead to functional impairment requiring surgical repair. According to American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) there are three important elements that must be documented to meet the requirement for functional indication for repair: clinical notes documenting patient complaints of visual impairment secondary to abnormal eyelid or brow position resulting in limitation of daily activities such as reading, driving, and difficulty seeing objects approaching from the periphery, or redundant upper eyelid skin resulting in looking through the eyelashes or seeing the upper eyelid skin; clinical notes documenting a margin reflex distance (MRD) of 2 mm or less for blepharoptosis repair; and peripheral visual field testing performed with the eyelid and brow in the resting position that documents a baseline superior visual field of 30 degrees or less from fixation and improvement of at least 12 degrees over baseline with eyelid and brow elevation. Both manual, including Goldmann and tangent screen, and automated fields are acceptable. The measurement of a patients superior visual field is defined as the lowest point seen at the vertical meridian. In this case, the patient meets all three requirements including documentation supporting MRD less than 2 mm and superior visual field restriction to 20 degrees in right eye which improves to more than 30 degrees with taping; and restriction to 25 degrees in left eye which improves to 30 or more with taping.  A technical guide to reading the visual field is to look at the vertical bar where each tick mark is 10 degrees. The large black squares indicate where the patient could not see. In the untapped right eye, the lowest dark square is at 20 degrees and possibly even 15 degrees. In the left it is at 25 degrees. Therefore, the request for eyelid surgery (CPT 67908  repair blepharoplasty conjunctive-tarso-mullers muscle-levator resection (1 unit) and CPT 15823  blepharoplasty upper eyelid with excessive skin (1 unit)) has been established as medically necessary. Final Result: The reviewer determined that the requested surgery 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 ophthalmology 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 61-year-old male enrollee has requested weekly individual sessions with a counselor for treatment of his panic disorder with agoraphobia.  Findings:  The physician reviewer found that cognitive behavioral therapy is a trusted therapeutic intervention for individuals with panic disorder.  Its safety and efficacy is supported by many well-designed studies and years of clinical experience.  Considering its chronicity, it is not uncommon for an individual with panic disorder to receive multiple treatments of cognitive behavioral therapy.  In the case of panic disorder refractory to first-line treatments, there is evidence supporting panic-focused psychodynamic psychotherapy, which is delivered individually.  The medical records offer no contraindication to individual sessions.  Based on the current peer-reviewed literature, individual therapy is medically indicated in this case considering the longitudinal course of illness coupled with the patients current presentation.  Thus, a course of 12 individual sessions delivered on a weekly basis is indicated.  However, a diagnostic reassessment to compare the clinical status with the pre-determined therapy goals and objectives following these 12 sessions is needed in order to establish the medical necessity of additional weekly individual sessions with a counselor.  All told, a portion of the requested weekly sessions with a counselor is medically indicated in this patients case
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 13-year-old male with cystic fibrosis diagnosed at the age of eight months. The patients mother indicates that the patients pulmonary lung function has decreased over the last three years. It does not appear that the patient is receiving treatment from a cystic fibrosis center. According to the submitted information, the patient has not seen a pulmonologist since 1998. The patient has been using The Vest for over a year. The Health Plan has denied authorization and coverage for the Vest on the basis that it is not medically necessary for treatment of the patients medical condition.Cystic fibrosis is an overwhelming disease in terms of family commitment and stress. The information submitted demonstrates that the ABI Vest has been beneficial for the patient. Experience at many cystic fibrosis centers is that the ABI Vest allows for more uniform chest treatment and increased compliance. Furthermore, there is sufficient scientific evidence demonstrating that the ABI Vest is safe and effective for patients with cystic fibrosis. Moreover, the Health Plan indicates the patient is unable to utilize a Flutter Valve effectively and the patients parents are unable to perform effective chest physical therapy Therefore, I have determined that the requested equipment 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:   An enrollee has requested substance use residential treatment center for treatment of his behavioral health conditions.  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  In this case, the patients illness burden had resulted in psychiatric sequelae and marital distress.  He did not have a supportive home or a meaningful sober network of social support at the time.  His self-proclaimed motivation for sobriety was inconsistent with his behaviors.  Following a residential stay earlier, he was unable to maintain sobriety with outpatient and community services.  Upon presentation, the patient had a mild withdrawal syndrome.  Further, he had multiple co-occurring chronic psychiatric conditions which compromised his prognosis.  Finally, the severity of the patients drug use represented a significant factor.  The patients drug use dominated his daily routine, and negatively impacted his relationships and caused significant impairment across multiple domains of functionality. All told, substance use residential treatment center services were medically necessary initially, but not subsequent to that time.   Final Result: The reviewer determined that a portion of the services at issue was 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 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 55-year-old male enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic studies. According to Chou and colleagues, Lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition. The clinical documentation provided for review did not indicate that the patient had any kind of nerve pressure or worsening pain prior to the diagnostic study being performed. There was no indication that the patient had attempted conservative therapy prior to the diagnostic study. There was no documentation that the patient had any severe or progressive neurologic deficits that would warrant the need for an MRI study. All told, the medical necessity for the MRI of the lumbar spine performed has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of psoriatic arthritis but it is has not been shown to be disease modifying. The American College of Rheumatology (ACR) recently released guidelines on the treatment of psoriatic arthritis in the setting of COVID-19. The ACR clinical guidance states that for patients with moderate to high disease activity despite optimal conventional synthetic [disease modifying anti-rheumatic drugs] DMARDs, biologics may be started. The ACR does not support treatment with Otezla due to the current COVID-19 pandemic. In this case, the patient does not have a history of failure or contraindication to biological DMARDs for treatment of her psoriatic arthritis. All told, the requested Otezla is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting authorization and coverage for Genotropin pen. Findings:  The physician reviewer found that the enrollee has a diagnosis of idiopathic short stature who was evaluated by an endocrinologist. Her bone age at age 13 years, 10 months was read as 12 years. Her endocrinologist indicates her height was below the 1st percentile and -2.36 standard deviations below the norm. Her growth velocity was 3.97 cm/year which was also below the 1st percentile for age and gender. Mid-parental height is 157.48 cm Insulin like growth factor (IGF) 1 was 1462 ng/ml. Her endocrinologist states it is imperative she receive growth hormone therapy. Review of the record indicates chemistry and lab data are normal except for IGF-1, which is greater than 2 standard deviations above the upper limit of normal. Her predicted height is estimated to be approximately 60 inches (152.4 centimeters, 4.4 percentile) and is within one standard deviation of the mid-parental height. The enrollee has short stature appropriate for a diagnosis of idiopathic short stature with a height less than -2.25 standard deviations and use of growth hormone therapy.  However, the indication for use of growth hormone therapy, as indicated by the FDA, also indicates the enrollee should have growth unlikely to result in normal adult stature. Humatrope is indicated for the treatment of idiopathic short stature, also called non-GH [growth hormone] deficient short stature defined by height SDS [standard deviation]  -2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range. This enrollee has a growth velocity of 12.55 centimeters per year and a height prediction of within one standard deviation of the mid-parental target height as well as above the 3rd percentile.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric endocrinology 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: Upheld

A 49-year-old female enrollee has requested for residential treatment services for treatment of her alcohol and opiate dependence. Findings:  The physician reviewer found that it appears from the record the patient made good progress towards recovery during her inpatient stay. She could have been treated at a lesser level of care as she no longer required 24-hour supervision to remain sober and to prevent relapse. By that point in her recovery, the patient could have been appropriately treated on an outpatient basis along with a community 12-step program.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for hemoglobin meter for home use. This patients records document hematologic complications of pancytopenia, which is likely a major component of her lupus exacerbation. Adequate monitoring involves more than just hemoglobin monitoring. Researchers noted that as progressive anemia can be multifactorial in lupus, disease activity monitoring should involve more than just hemoglobin monitoring. The authors discussed that the current standard of care for lupus monitoring include full blood count, serum creatinine and albumin, C-reactive protein, and estimated glomerular filtration rate (eGFR). There is a paucity of data in the medical literature demonstrating that home monitoring of this patients hemoglobin will be more effective in managing her condition than standard of care recommendations. Therefore, the requested hemoglobin meter for home use is 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 device is 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Panasol 3D Ultraviolet (UV) Device for home use. Vitiligo is a medical illness that can cause severe psychosocial distress to patients. Narrow band ultraviolet phototherapy (NB-UVB) is a well-accepted and effective therapy for generalized vitiligo as it leads to some degree of repigmentation and is supported by high quality evidence in the medical literature. For generalized lesions, many providers consider NB-UVB for first-line therapy. In-office treatment requires multiple treatments per week. Patients who are unable to receive in-office treatment may be good candidates for a home-based unit and protocol. One randomized controlled trial found that a home device can be as effective as in-office therapy, with better compliance rates. In this case, the patient has demonstrated response to in-office NB-UVB therapy, and it is reasonable to suspect continued therapy at home would be beneficial. The patient is unable to attend in-office treatment sessions due to graduate school commitments. Given these findings, the requested Panasol 3D Ultraviolet (UV) Device for home use is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 dermatology 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 48-year-old male enrollee has requested home ultraviolet phototherapy for treatment of his psoriasis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  Ultraviolet light phototherapy may be an effective treatment for psoriasis in some cases.  The Health Plan has required a trial of office-based phototherapy prior to providing coverage for home ultraviolet phototherapy.  The Health Plans requirement is medically appropriate.  The submitted records do not demonstrate that the patient has had a trial of in-office phototherapy to show that it is tolerated and efficacious for this patients disease.  All told, home ultraviolet phototherapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested reimbursement and prospective authorization and coverage for ranibizumab (Lucentis) injections. The Health Plan has denied this request indicating that the therapy at issue was and is considered investigational for treatment of the enrollees right eye macular edema secondary to branch retinal vein occlusion (BRVO). Findings:  Two physician reviewers found that the patient has macular edema secondary to retinal vein occlusion. Specifically, the patient recently experienced a branch retinal vein occlusion (BRVO) in the right eye with resultant decreased visual acuity due to macular edema. The clinic notes document a plan to treat with Avastin or Lucentis.  The patients request was denied by the Health Plan as investigational in this clinical setting. Macular edema is a chronic condition that can be difficult to treat and can be refractory to conventional therapy. If not successfully treated macular edema can lead to permanent loss of vision. It has become the standard of care to treat retinal vascular disorders and the resultant macular edema with an anti-VEGF agent such as Avastin or Lucentis. Moreover, the Health Plans policy specifically states that the use of these agents is considered medically necessary as a treatment forbranch retinal vein occlusion. This patients records clearly support a diagnosis of BRVO, thus she should undergo treatment with Lucentis injections as they may offer her superior results when compared with standard therapy.