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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for voice therapy. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH further states that, voice and communication therapy may help to alleviate gender dysphoria and be a positive and motivating step towards achieving ones goals for gender role expression. The WPATH does not require a mental health evaluation for voice therapy. This patients records document a history of gender dysphoria with distress related to the masculine sound of her voice. For this patient with severe gender dysphoria, voice therapy is indicated to help her voice be more consistent with her female gender identity. Therefore, the requested voice therapy is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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

An 18-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his behavioral health condition.    Findings:  The physician reviewer found that based on the clinical data provided, the initial residential level of care was medically necessary as the patient was symptomatic despite prior treatment in a less restrictive setting. The patient initially presented with erratic behavior. He was threatening and assaultive thereby posing a danger by others. Thus, admission to a residential treatment level of care was medically necessary and appropriate. However, by the date indicated, the patients condition had improved to the point that he was appropriate for transition to a less intensive level of care. A note  indicates that the patient was much more relaxed. He was able to articulate his frustration with a peer that made him want to kick the individual, but he had not acted on these urges.  His mother shared her feelings over a matter of concern and the patient seemed to accept the limit better than in the past. Based on the documentation provided, there were no reports of functionally impairing psychiatric symptomatologies from the date indicated onward. The patient was sleeping well. He was tolerating medications and the regimen was not being adjusted. There was no evidence of safety concerns to self or others, or disruptive behaviors on the unit. He was responding well to parental limits. There was no evidence that treatment in a less restrictive setting would hinder further improvement or generate a more serious episode of illness. Additionally, according to the hospital discharge summary on the date indicated, the parent reported that the patient has not been in treatment recently. Thus, transition to a less intensive level of care with comprehensive services to continue his recovery, capitalizing on the therapeutic gains garnered from the residential programming, is not contraindicated. Considering these variables, clinical presentation, and relevant peer reviewed literature, the residential treatment center services were medically necessary from the time frame specified, but not thereafter.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the intermittent limb compression device not otherwise specified (cooling or combined heating/cooling unit) CPT code E0676 for treatment of her status post hip and knee surgeries. Two physician reviewers found that the device at issue provides intermittent sequential compression therapy intended as deep vein thrombosis (DVT) prophylaxis, intermittent dynamic compression therapy intended to reduce swelling, and controlled cold therapy intended to reduce both pain and swelling. In this case, there are no identified risk factors for DVT. If DVT prophylaxis was determined to be necessary, there is no contraindication to use of an oral or injected agent for DVT prophylaxis such as warfarin, fondaparinux or rivaroxaban. In this clinical setting, the intermittent limb compression device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result:  Two reviewers determined that the device at issue was 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 physical medicine and rehabilitation 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Apokyn injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients Parkinsons disease. The submitted documentation supports the medical necessity of the requested medication. Studies show that motor fluctuations are common and distressing for patients with advanced Parkinson's disease. Subcutaneous apomorphine injections were noted to be an extremely valuable adjunctive therapy, given that it helped with motor fluctuation symptoms due to off periods. Studies recommended that Apokyn was clinically helpful for treatment of motor fluctuations. The available clinical studies indicate that apomorphine, also known by the brand name Apokyn, is effective in providing prompt and consistent rescue from `off` episodes in patients with Parkinsons disease. The medical records submitted for review document findings consistent with motor fluctuations due to Parkinsons disease. Motor fluctuations due to off periods can only effectively be treated with Apokyn. As such, Apokyn injections are medically necessary at this time for the treatment of this patient.Final Result: The reviewer determined that the medication 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 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: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested for repeat bilateral Synvisc One viscosupplementation injections to the knees for treatment of his knee pain.  Findings:  The physician reviewer found that viscosupplementation has been generally accepted as a component in the treatment of osteoarthritis of the knee in appropriate patients, and it is most suitable in patients with mild to moderate disease. It is more efficacious in patients with non-radiologically severe osteoarthritis with no or mild effusion. The role of repeated courses of therapy is more controversial. There is an increase in the reported occurrence of adverse reactions in patients who have received multiple course of therapy, as noted by Leopold and colleagues. After a period of time, a second course of treatment is well-tolerated, but there is a paucity of reported evidence regarding the safety and efficacy of further courses of injections. All told, the requested bilateral Synvisc One viscosupplementation injections to the knees are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old female enrollee has requested for Synvisc injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the record submitted does not include this treatment or the patients clinical response to the corticosteroid injections. Standard of care requires that the efficacy of the steroid injections be assessed by her provider. If it is determined that the patient failed to respond to this intervention, then it is appropriate to consider Synvisc injections.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 45-year-old man who has psoriasis of the trunk and extremities, which his dermatologist describes as severely disabling. The ineffective therapeutic attempts include topical corticosteroids, phototherapy, sunlight and over the counter medications. Clinically, excellent improvement was achieved with Excimer laser treatment two to three times a week. At issue is whether the laser treatments were medically necessary.The submitted clinical information includes notes from the patients treating dermatologist documenting the effectiveness of Excimer laser therapy for this patient. The references provided document the efficacy and safety of the treatment, as well as its mechanism. Excimer laser is approved by the FDA for the treatment of psoriasis and is considered an appropriate choice for treatment of the condition. The laser therapy the patient received was medically indicated and clinically effective. Accordingly, I have determined the therapy at issue was 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: The patient is requesting reimbursement and prospective authorization and coverage for (1) Xtampza ER capsules and (2) Xtampza ER capsules. Findings: On determining when to initiate or continue opioids for chronic pain, a study finds, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic pain due to spondylosis of the spine. They have been managed on a medication regimen, including Xtampza and oxycodone, along with interventional procedures. The records note that the patient is at low risk for medication misuse and has not shown aberrant or drug seeking behavior. Given that the patient is stable on his current medications for pain management, the medication at issue was and is medically indicated. Therefore, (1) Xtampza ER capsules and (2) Xtampza ER capsules were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-three year-old female with chronic heel pain is requesting authorization of extracorporeal shock wave therapy (ESWT).  The patient has under gone a number of procedures with out success.  Reviewers Findings:The reviewing physician found that it is medically reasonable and appropriate to attempt ESWT given the failure of multiple modalities.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees chronic hepatitis C virus genotype 2. Findings:  The physician reviewer found that According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is ot 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Genotropin (somatropin [rDNA origin] for injection) 5 mg/mL for treatment of his short stature. Findings:  The physician reviewer found that the Genotropin (somatropin [rDNA origin] for injection) 5 mg/mL was and is medically necessary for treatment of the patients medical condition. The patients pre-treatment height was below the 1st percentile. In addition he had poor growth velocity, his adult predicted height was more than two SDs below the average U.S. male adult height, and he had low serial IGF-1 levels. Although he passed GH provocative testing, he meets criteria for GH treatment based on the U.S. Food and Drug Administration (FDA) approved indication for idiopathic short stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SD below the mean for age; (4) low serum IGF-1 and/or insulin-like growth factor-binding protein 3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient does meet most of the above criteria, and his adult predicted height of 61 inches is short enough to warrant GH therapy based on current FDA standards for treatment of idiopathic short stature.  Final Result: The reviewer determined that the medication at issue was and 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 pediatrics with sub-specialty certification 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that breast 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records note dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed was likely to have been more efficacious than other methods of evaluating this patient.  Final Result: The reviewers determined that the service at issue was 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: the physician reviewers are board certified in diagnostic radiology 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: Overturned

A 57-year-old male enrollee has requested for Avastin and Abraxane combination therapy for treatment of his metastatic melanoma.   Findings:  Two physician reviewers found that there is essentially no standard therapy for metastatic melanoma. As such, national guidelines often recommend clinical trials in this setting; however, for various reasons most patients are not eligible for participation in such trials. With regard to systemic therapy in this setting, a phase II study of the combination of Avastin/Abraxane has been reported with very promising results (see Rao and colleagues). In addition, Abraxane is a reformulation of paclitaxel, and has in general been found to be more effective and less toxic than native paclitaxel. Paclitaxel is included in national guidelines for melanoma. However, most importantly, this patient has been treated with this combination in the past and has had an excellent response. This is the single best predictor that this regimen is likely to be efficacious for this patient in the future.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine adhesive patch 5%. The U.S. Food and Drug Administration (FDA) has approved the lidocaine patch for the treatment of patients with post-herpetic neuralgia. A review by researchers reported that there is a lack of evidence to support the use of lidocaine patches for the treatment of musculoskeletal pain. A systematic review completed by researchers evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors analyzed seven studies and concluded that there is a paucity of randomized controlled trials with substantial evidence to support the use of 5% Lidocaine patch in chronic low back pain. In this case, the patient has chronic low back pain due to high grade spinal stenosis. Her records do not report any history of symptoms suggestive of post-herpetic neuralgia. Moreover, the providers notes document that the lidocaine patch was not effective for relief of this patients chronic back pain, which is consistent with the current evidence-based medical literature. All told, the requested lidocaine adhesive patch 5% 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 anesthesiology with subspecialty certification in pain management 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 parent of an enrollee has requested eye movement desensitization and reprocessing (EMDR) therapy for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with autism spectrum disorder, speech/language disorder and academic difficulties. The requested services are not clinically indicated in this clinical setting. EMDR therapy is a therapeutic technique that only has utility in treating individuals diagnosed with PTSD. The documentation submitted for review does not demonstrate a diagnosis of PTSD. In this clinical setting, the peer-reviewed literature recommends behavioral interventions such as ABA therapy, which this patient is currently receiving. For the reasons provided above, the request for EMDR therapy is not indicated for 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 sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.