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

The representative of a 19-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of his behavioral health condition. Findings:  The physician reviewer found that acute psychiatric hospitalization was initially indicated for this young man with a history of violent behavior and emotional dysregulation. Due to the patients unpredictable aggressiveness at home, he was placed on an involuntary hold. During the hospitalization, the patient was not witnessed to be violent by staff.  Per the physician transfer of care note on the specified date, the patients boundary mismanagement and social inappropriateness were responsive to verbal de-escalation and redirection. Although the patient demonstrated social oddities consistent with the diagnosis, he had a linear flow of thought with unimpaired cognition. Although there was no evidence of grave disability, inability to provide basic self-care, or imminent threat to self, during a family meeting it was reported that the patient remained violent and threatening outside of staffs awareness, effectively raising the concern for on-going threat to others and underscoring the importance of a coordinated discharge to a group home. In reading the social work note, it is inferred that appropriate facilities were available for discharge.Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the medical necessity of inpatient psychiatric hospital services to the present and onward has been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hair transplant to cover scar at hairline on forehead, rhinoplasty revision, and tracheal shave. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. The WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. Medical literature demonstrated that facial feminization surgery improved mental health-related quality of life. The records provided for review demonstrate that this patient underwent facial feminization surgery and is not satisfied with the results. The patient reports difficulty securing employment due to discrimination and being misgendered. However, the documentation does not include evidence from the patients providers that the requested facial feminization surgery revision including hair transplant, revision of rhinoplasty, and tracheal shave, are indicated to address the patients distress related to her gender dysphoria. For these reasons, the requested hair transplant to cover scar at hairline on forehead, rhinoplasty revision, and tracheal shave are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in transgender health 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 parent of a 4-year-old female has requested applied behavioral analysis (ABA) therapy for treatment of her autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Thus, it is medically necessary that this patient receive ABA therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female has requested total disc replacement surgery using ProDisc-C for treatment of her neck pain and upper extremity pain.  Findings:  Three physician reviewers found that the patient reports neck pain which radiates down the left upper extremity to the wrist.  She reports numbness in all fingers of her left hand and difficulty with daily activities secondary to pain.  The patient has tried medications, physical therapy, and a TENS unit, which did not result in significant pain relief.  An MRI of the cervical spine showed mild C5-6 spondylosis and a moderately sized left disc extrusion resulting in moderate stenosis of the left lateral recess and left neural foramen.  The current medical literature has not demonstrated the superior efficacy of the requested procedure in this patients case.  Porchet and Metcalf (55 patients), Hacker (46 patients), and Coric and colleagues (33 patients) all reported randomized series of patients with cervical degenerative disease who underwent either arthroplasty or anterior cervical discectomy and fusion.  Per these studies, both the arthroplasty and anterior cervical discectomy and fusion groups showed clinical improvement.  The arthroplasty group experienced preservation of range of motion at the surgical level.  However, these studies were graded Class II because it was not evident how randomization occurred and whether the assessments were done by blinded observers.  More recently published reports of randomized trials with longer term follow-up suggest that artificial disc replacement may be beneficial, but the percentages of patients receiving four-year (55% of patients) and five-year (50% of patients) follow-up are exceedingly low.  Thus, the requested total disc replacement is not likely to be of greater benefit than other treatment options in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) infusions.Findings:  Two of the three physician reviewers found that PANDAS is a term used for children that have abrupt onset of tics and/or obsessive-compulsive disorder symptoms following group A beta hemolytic streptococcal infection. There has been debate over optimal and appropriate treatment for children that carry this diagnosis. Many children respond to bacterial eradication. Some children remain symptomatic despite multiple courses of antibiotics and symptomatic treatments for the behavioral concerns. For this latter group of patients, the use of IVIG has become standard of care to address more complex diagnoses, such as immunoglobulin G (IgG) deficiency and autoimmune encephalitis. The current standard of care involves use of immunomodulatory agents for more complex and/or refractory cases. This patient represents such a case, with persistent symptoms despite multiple courses of antibiotics, as well as other therapies, such as selective serotonin reuptake inhibitors (SSRI) therapy. The use of IVIG is standard of care in this setting. Therefore, IVIG infusions are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and are actively practicing. Physician reviewer 3 is board certified in pediatrics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has chronic low back pain, sciatica, chronic neck pain and cervical radiculopathy. The patient was treated with acupuncture for his conditions. He was diagnosed with chronic spondylosis and stenosis of the entire spine. He has degenerative disc disease through the cervical spine and the lower lumbar spine. He underwent three epidural injections, utilized opioid pain medications, tried physical therapy, and started acupuncture. He had 18 treatments of acupuncture for the cervical radiculopathy and left shoulder pain, which helped his left shoulder pain and somewhat improved his chronic upper back pain. He also had eight treatments of acupuncture for his thoracic spine pain and leg myalgia, which helped his leg pain somewhat but not his buttocks and mid back. Per a report, the patient has worsening neck and left upper extremity pain of seven to eight out of 10, and acupuncture only helps temporarily. The patient has received sufficient acupuncture treatment to his neck and low back. He has not reportedly made any sustained and significant improvement after 26 total treatments with two different providers. He indicates that he experienced temporary relief with treatments. However, he is not reasonably expected to make further sustained improvement through more treatment. Acupuncture is an effective short-term treatment for patients with chronic neck pain. However, there is only limited evidence for long-term effects. Also, studies show that acupuncture is not clinically more effective than sham-acupuncture or placebo for neck or back pain. The patient has been referred for surgical management due to the lack of relief of conservative measures. Acupuncture is not supported as medically necessary for his condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a board certified chiropractor licensed in oriental 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 4Kscore test (CPT code 81539) and the ConfirmMDx gene test (CPT code 81551).  This patient with an elevated PSA underwent 4Kscore testing and ConfirmMDx testing to help assess his risk for prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines do not consider 4Kscore testing or ConfirmMDx the standard of care for evaluation of patients with elevated PSA levels. While 4Kscore or ConfirmMDx may eventually have a role in this clinical setting, there are insufficient data on long-term patient health outcomes to support routine use in screening patients for prostate cancer. For these reasons, the 4Kscore test (CPT code 81539) and the ConfirmMDx gene test (CPT code 81551) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the 4Kscore test (CPT code 81539) and the ConfirmMDx gene test (CPT code 81551) were 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 services at issue were 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 reviewers 1, 2, and 3 are board certified in urology 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for foot orthotics/shoe inserts. Medical literature note that most disease conditions that affect the hallux are amenable to conservative treatment prior to focusing on surgical management. In this case, the patient is a cross-country track runner who reports pain in the ball of the right foot for the past three months, aggravated when running. The patients diagnoses include pain in the right foot and sesamoiditis. The provider recommends that the patient be casted for functional orthotics in order to decrease pronation, decrease stretch of the plantar fascia, delay the formation of bunions, delay the formation of hammertoes, increase shock absorption, and prevent surgery. In this clinical setting, the requested equipment is medically indicated. Therefore, foot orthotics/shoe inserts are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 podiatrist and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested Real-Time Remote Heart Monitor for an evaluation of his arrhythmia. Findings:  Three physician reviewers found that remote event monitoring is becoming an accepted modality for use in the detection of cardiac arrhythmias. In this case, however, the use of the device was not indicated at the time it was performed. Based on the records provided, the patient had been free of symptoms for months, nuclear stress and echocardiogram studies failed to reveal significant pathology of any sort, and two Holter recordings provided no additional insight. While it might have been considered reasonable to pursue a remote event recorder at a time when the patient was more symptomatic, the most opportune time for detecting arrhythmia had passed. As such, the use of a Real-Time Remote Heart Monitor was not likely to have been a more effective method of evaluating this patient than standard alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of the Inspire upper airway stimulation system.Findings:  Three physician reviewers found that obstructive sleep apnea is an increasingly prevalent clinical problem. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. Hypoglossal nerve stimulation has been demonstrated to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment for moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with continuous positive pressure therapy and who have appropriate polysomnographic, age, body mass index and objective upper airway evaluation measures. With a body mass index of 28.37, apnea-hypopnea index of 34.1, and nonconcentric airway collapse, this patient meets the criteria. He has failed continuous positive airway pressure therapy, which is the gold standard treatment for obstructive sleep apnea. Thus, implantation of the Inspire upper airway stimulation system is likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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: Medical Necessity
Decision: Overturned

The patient is a 51-year-old male who is requesting authorization and coverage for the medication Levitra for treatment of erectile dysfunction. His history is positive for HIV, anxiety and insomnia and he is being treated medically for these conditions. The Health Plan has denied the patients request for Levitra on the basis it is not medically necessary.Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. The 5-phosphodiesterase inhibitors such as Viagra and Levitra are accepted primary therapy for erectile dysfunction. These medications are effective for approximately 70% of patients who have no contraindications or side effects. Based upon the information provided, it does not appear the patient has been tried on Levitra. A trial of Levitra is medically appropriate and indicated for this patient.Based upon the information set forth above, I have determined that a one-month trial of Levitra is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. If the trial is effective, Levitra should continue to be authorized. However, if the trial of Levitra is not effective, Levitra should no longer be authorized.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female who has requested authorization and coverage for a myomectomy. The patient has a history of abnormal uterine bleeding since January 2004. A pelvic sonogram showed three uterine fibroids measuring 14mm, 2.5cm, and 3.3cm. The patient had a negative endometrial biopsy and a negative hysteroscopy. The submitted records indicate she has had no dysmenorrhea or dyspareunia. A complaint of pelvic pain was felt to be due to a neurological cause. Her hemoglobin was normal. The Health Plan has denied coverage for a myomectomy indicating it is not medically necessary for treatment of the patients uterine fibroids.Essentially, the patient has asymptomatic uterine fibroids, which are very small. This is not an indication for surgery. The patient indicates she wishes to preserve her future fertility and has requested a myomectomy. A myomectomy is not clinically indicated in this case.  If, hypothetically, a myomectomy was scheduled, the patient would have to sign a consent allowing a hysterectomy to be performed if there was excessive bleeding, which occurs not infrequently during the requested procedure. Also, pelvic adhesions could result from the surgery, which can cause infertility. Therefore, the treatment of these uterine fibroids by surgery could have deleterious effects.It would appear a 48-year-old with irregular bleeding might have dysfunctional uterine bleeding due to fluctuating hormonal levels. When the patients estrogen levels decrease during menopause the existing fibroids may shrink in size. The standard of practice for patients such as this patient are oral contraceptives, progesterone, Lupron, and perhaps endometrial ablation. A myomectomy is not clinically indicated for treatment of the patients condition.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested Lexapro 10mg for treatment of his anxiety.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the medication at issue. While the patient is noted to have anxiety, there have been various diagnoses, including post-traumatic stress disorder and generalized anxiety disorder. There is no psychiatric evaluation supplied in accordance with American Psychiatric Association standards which leads to a specific diagnosis for which the requested medication is indicated.  The American Psychiatric Association guidelines for post-traumatic stress disorder indicate SSRIs as the hallmark of treatment. However, there is no information in the record justifying why a formulary SSRI could not reasonably be tried for the purpose of mitigating the patients anxiety. Given the availability of potential alternatives which apparently have not been tried, this medication was not and is not medically necessary for this patients condition according to current evidence-based practice standards and expert consensus. All told, Lexapro 10mg was not and is not medically indicated for the treatment of this patient.