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

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested authorization and coverage for facial feminization surgery. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees gender dysphoria. At issue in this case is whether the requested facial feminization surgery is medically necessary for treatment of the patients behavioral health condition. Medically necessary gender affirming/confirming surgical procedures are described in section XI of the WPATH standards of care. These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient; including, for example, skin flap hair removal; scrotoplasty and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These procedures are reconstructive surgeries. The patient has a documented history of gender dysphoria, has been on cross gender hormone therapy, and has had other gender confirming surgeries specifically vaginoplasty and orchiectomy. Facial feminization surgery (FFS) would provide reconstructive surgical services for an abnormality as a result of the disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. Based on the documented history of gender dysphoria and evidence of the medical necessity of FFS, the requested facial feminization surgery is medically necessary.Final Result: The reviewer determined that the requested procedures 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 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 35-year-old female enrollee requested authorization and coverage of an MRI of the brain. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees numbness and tingling sensations.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female has requested coverage for past nasal surgery (radiofrequency of the bilateral nasal turbinates) performed for treatment of her sleep apnea.  Findings:  Two physician reviewers found that the patient has sleep apnea with a respiratory disturbance index (RDI) of 16. She has had previous surgery and has been unable to tolerate continuous positive airway pressure (CPAP). She was found to have obstructive 3+ turbinates.  The only method of treatment with the fewest risks given her medical problems is a radiofrequency reduction of the turbinates. Radiofrequency turbinate reduction is a standard treatment of turbinate hypertrophy in patients with sleep apnea (Troell, et al). In addition, radiofrequency turbinate reduction improves the quality of life in patients with sleep apnea (Li, et al). For these reasons, the surgery at issue was likely to be more beneficial for this patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested for TOBI (tobramycin inhalation solution) for treatment of his chronic sinusitis. Findings:  The physician reviewer found that antimicrobial therapy delivered via nebulization technique can potentially benefit patients. However, careful review of the long-term outcome does not show any significant benefit over other more common therapies. Usually, the topical administration of nebulized therapy is an adjunct to other medications and other therapies. The current medical literature does not establish a standard for this medication under these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved. That is, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. While in this patient the extra radiation dose is not a factor, as the 2D images were reconstructed from the primary tomosynthesis acquisition, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology 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 diagnostic radiology 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 diagnostic radiology 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:  The enrollee requested authorization and coverage for a Transoral Incisionless Fundoplication (TIF) procedure utilizing the EsophyX device. The provider recommended an esophagogastroduodenoscopy (EGD), colonoscopy and upper gastrointestinal (UGI) series. The UGI showed severe GERD while supine, potential retropharyngeal component and a small, sliding type HH. EGD results from showed a mildly irregular z-line, mild gastritis and a normal appearing lower end esophagus.The provider does not believe the patient has any contraindications for the procedure. Professional societies note the Transoral Incisionless Fundoplication (TIF) utilizing the EsophyX device can be performed with an acceptable risk in appropriate individuals. The medical literature indicates the safety profile of TIF and its effectiveness in eliminating typical and atypical gastroesophageal reflux disease supports the adoption of this treatment as an alternative treatment for selected individuals with inadequate symptom control on PPI therapy. TIF can be used to achieve long-term control of chronic GERD symptoms, healing of esophagitis, and improvement in esophageal acid exposure. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a female enrollee requested inpatient mental health services for medical treatment of the enrollee's behavioral health condition.  Findings:  The physician reviewer found that the documentation provided for review did not describe an acute psychiatric syndrome, grave disability or medical illness that necessitated services at the acute level of care.   There was no evidence to suggest that treatment in a less restrictive setting would have been unsafe or unreasonable based on the documentation provided. Thus, the inpatient mental health services were not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tymlos Pen Injector. Findings: Tymlos is a parathyroid hormone analogue that increases bone formation. Guidelines indicates that Tymlos is indicated in patients with severe osteoporosis and patients with multiple vertebral fractures. Per the Endocrine Society guidelines, severe osteoporosis is defined as a T score of -3.5. In this case, the patients DEXA scan showed worsening scores from -2.7 to -3.2, which does not support severe osteoporosis. In addition, there is no documentation of recent or previous vertebral fractures. Based on these findings, the patient does not meet the criteria for initiation of Tymlos therapy for the treatment of severe osteoporosis or for multiple vertebral fractures. Therefore, the requested Tymlos Pen Injector 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 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

The parent of a 17-year-old male enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the records indicate that the patient has idiopathic short stature with normal growth factors. The patients epiphyses are nearly fused, and he is already past the peak of his growth spurt. The addition of exogenous growth hormone therapy will not improve his height potential at this time. Therefore, the requested Genotropin growth hormone therapy is not supported as 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 reimbursement for contrast-enhanced computed tomography angiography (CTA) scan. This patients provider noted that the patient has a history of metastatic adenocarcinoma of the lung and cardiomyopathy. A computed tomography (CT) of the chest revealed stable perihilar right upper lobe mass-like consolidation, new irregular nodular opacity in the lingula, and stable appearance of thickening involving the septal apically segment of the left ventricle. The provider recommended a contrast-enhanced CTA to assess the patient for coronary artery disease as the cause of his cardiomyopathy. Current peer-reviewed medical literature has demonstrated that contrast-enhanced CTA has diagnostic utility and prognostic significance in this patient and is a standard of care approach. All told, the contrast-enhanced CTA scan was 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 contrast-enhanced CTA scan was 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 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 1 is board certified in oncology 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 medical oncology with subspecialty certification in hematology 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

The patient has requested authorization and coverage for proton beam therapy (CPT codes 77520, 77522, 77523, and 77525). Currently, there a paucity of clinical data to support treatment with proton beam radiation in lieu of conventional radiation therapy techniques in the treatment of prostate cancer (Sheets, et al.). One analysis evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, the authors found that the patients treated with IMRT experienced a lower rate of gastrointestinal morbidity, and there were no other significant differences regarding toxicities between IMRT and proton therapy reported. Another analysis of early toxicity compared 421 patients treated for prostate cancer with proton therapy and 842 matched case controls treated with IMRT (Yu, et al.). The authors noted a statistically significant decrease in genitourinary toxicity at six months with proton therapy. However, this difference disappeared by one year and there were no other significant differences in toxicity observed between the two techniques. A position statement released by the American Society of Radiation Oncology (ASTRO) states that, the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO and state that there is a lack of evidence demonstrating a clinical benefit of proton therapy over standard treatment with photons and IMRT technique. The records provided for review demonstrate the patient has an elevated PSA with Gleason 3+3 adenocarcinoma of the prostate. Based on the patients work-up, he is a candidate for conventional radiation therapy with IMRT or conformal radiation therapy. There is a lack of data to support an indication for proton beam therapy instead of photons due to the patients hydronephrosis or other clinical finding. For these reasons, the requested proton beam therapy (CPT codes 77520, 77522, 77523, and 77525) is 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.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested for lumbar spinal fusion surgery and a 3-day hospital admission for treatment of her degenerative disc disease.  Findings:  The physician reviewer found that Resnick and colleagues conducted a comprehensive review of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, and concluded that, Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. The authors suggest the standard of care for lumbar spinal fusion is to be recommended as a potential surgical adjunct in patients with a herniated disc with evidence of pre-operative lumbar spinal deformity or instability, or in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. Applying these recommendations, this lumbar spinal fusion is not indicated for this patient at this time. While her discogram does demonstrate axial pain, the authors advise against spinal fusion as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested re-admission into a skilled nursing facility (SNF) for treatment of his cellulitis, sepsis with organ dysfunction and septicemia, atrial fibrillation, and dyspnea.  Findings:  The physician reviewer found that this patients records indicate that he has reached a level of function that did not require daily skilled therapy to restore or maintain function. Continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist. The patient was functioning at a standby assistance level for bed mobility and transfers. This level of rehabilitation does not require daily inpatient skilled therapy (Ward, et al). Daily inpatient skilled therapy is not necessary or required to restore or maintain function. His daily medication management for his diabetes is not a skilled service and is a task that may be assisted by non-professional caregivers. The Centers for Medicare and Medicaid Services (CMS) criteria for skilled care coverage indicates that routine diabetic care is not a daily skilled service. All told, skilled services are not medically necessary to establish a maintenance program, to prevent deterioration of the patients condition, or manage his daily health care needs.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee's parent has requested authorization and coverage for 24 therapist hours per week and 25 supervisor hours per month of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, for 24 therapist hours per week and 25 supervisor hours per month of ABA services are not medically necessary for treatment of the patients autism spectrum disorder. ABA therapy covers a variety of methods concerned with the application of behavioral science to socially important functions, particularly in individuals with intellectual disabilities. Common features of ABA-based therapies include the objective measurement of behavior, structured control of the environment, and the implementation of procedures based on scientifically established principles of behavior. In this case, the documentation indicates that the Health Plan has authorized a three-month bridging period of ABA therapy with an in-Plan ABA provider. As such, the requested services have not been established as medically necessary for treatment of the patients medical 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 board certified in pediatrics and neurology with special qualification in child neurology 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 use of a computer-assisted device during surgery for treatment of his medical condition. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this patients case.  Evidence-based medical guidelines and peer-reviewed literature indicate that there is inadequate data to permit scientific conclusions regarding computer-assisted surgery.  Additionally, there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of computer-assisted navigation in the specific treatment of wrist fracture dislocations.  Therefore, the use of a computer-assisted device was not likely to have been superior over other treatment options.  Final Result: Two 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: All three reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.