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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser removal of facial hair. Findings:  The physician reviewer found that per World Professional Association for Transgender Health (WPATH) Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A., in addition to hormonal balancing, medically necessary gender affirming/confirming surgical 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.In this patients case, review of medical records support that gender dysphoria was persistent, severe, and related to, facial hair. Based upon the self-identified relationship of masculine facial hair and her gender dysphoria, the requested services are medically appropriate. Therefore, the requested laser removal of facial hair is medically necessary for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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 64-year-old female enrollee has requested Botox injections for treatment of the enrollees trochleitis. Findings:  Three physician reviewers found that at this time, there is a lack of scientific evidence demonstrating the benefit and long-term safety of Botox for trochleitis.  The efficacy of the use of Botox in this clinical situation has not been established.  The current medical literature has not shown that Botox is superior to standard therapies for this patients condition.  All told, the superior efficacy of Botox for the treatment of this patient has not been established by the current medical evidence.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for genetic testing (cytogenomic SNP microarray). The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees congenital cytomegalovirus and developmental delay. At issue in this case is whether the requested genetic testing (cytogenomic SNP microarray) is medically necessary for treatment of the patients medical condition.Per researchers, the clinical utility of chromosomal microarray (CMA) is well established. CMA is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information. In a study, a retrospective chart review of CMA testing was performed on individuals with developmental delay; intellectual disability; autism spectrum disorders and congenital anomalies in order to determine the proportion of cases where abnormal CMA results impacted recommendations for clinical action. Among the 1792 patients that were reviewed, 13.1 percent had clinically relevant results. When an abnormal result was identified, a recommendation for clinical action was made 54 percent of the time. Findings in this study clearly demonstrated that CMA results influenced medical care in the majority of patients by precipitating medical referrals; diagnostic imaging; or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. Per researchers, recent evidence-based international guidelines promote the use of CMA as a first-tier investigation for global developmental delay. This is if no etiological indicators from history and examination are found. The higher sensitivity that it has for identifying submicroscopic deletions and duplications (than standard karyotyping methods) and better definition of the breakpoints and size of imbalances all make CMA a suitable first-line test. This patients clinic picture is significant for hypotonia, severe microcephaly and global developmental delay in the context of congenital CMV. In this clinical setting, CMA testing is supported as an important diagnostic tool for this patient. Therefore, the genetic testing (cytogenomic SNP microarray) is medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in clinical genetics and genomics, and pediatrics with subspecialty certification in developmental-behavioral pediatrics 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 reimbursement for the additional physical therapy (PT) sessions for treatment of the enrollees intradural pilocytic astrocytoma.  Findings:  The physician reviewer found that the additional physical therapy sessions provided were medically necessary for the treatment of the patients medical condition. There is sufficient medical literature supporting the services at issue in this clinical setting. One study systematically reviewed the evidence for the efficacy of different rehabilitation strategies on functional ambulation following spinal cord injury. The study notes that rehabilitation strategies that facilitate repeated practice of gait offer the greatest benefits to functional ambulation in sub-acute or chronic spinal cord injury. Supportive devices may augment functional ambulation particularly in people with incomplete spinal cord injury. Another study performed a literature review on interventions for gait in patients with pediatric spinal cord impairments. The study reports that it is important to identify individual patient characteristics and goals appropriate for each intervention to guide clinical practice. Determining the appropriate orthotic support for each child, and incorporating treadmill training or electrical stimulation, is recommended. Moreover, the authors indicate that intensive gait training, including practice overground, results in notable improvements, with a trend for greater gains with greater total training durations. In this case, the patient is active and highly motivated to obtain the best possible outcome of his therapy. He plays sports including tennis. He indicates that he wants to be able to walk without a limp. In addition, his physical therapy goals are aimed at improving the strength in his right leg, and to enable him to walk without an obvious limp, using the least restrictive orthosis available. These goals are realistic, and per the records submitted they have not yet been met. However, the patient is making progress towards these goals. For the reasons provided, the additional physical therapy sessions provided have been established as medically necessary for treatment of the patients medical condition. Final Result: The physician reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The physician reviewer is board certified in pediatrics and 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: Overturned

The parent of a five-year-old male enrollee has requested occupational therapy one time per week (using codes 92526 x 1, 97530 x 2 for a total of 92526 x 12 and 97530 x 24) for treatment of the enrollees feeding disorder.  Findings:  The physician reviewer found that this patient demonstrated severe dietary self-imposed restrictions.  Essentially, he was limiting himself to chicken nuggets as his major caloric intake. His dietary preferences had a psychogenic etiology. However, the etiology of the patients food aversion is not clear from the records.  The study by Mannella and Trabulsi discusses childhood limited food selection as a harbinger of a poor adult choice of diet and the authors stress that increasing fruit and vegetable consumption early in life may lead to an adequate life-long intake of fruits and vegetables, which will be beneficial for weight control and prevention of cardiac dysfunction later in life.  Food desensitization, such as introduced by the occupational therapist, is an important component of eliminating selective feeding by a child (Tamura, et al.). Additionally, parenting and the social environment are important factors in the development of eating behaviors (Gahagan). Thus, it is important for an outside influence to alter this patients eating behaviors. The patients long range health is being jeopardized by his poor dietary habits. Therefore, the recommended occupational therapy is medically necessary and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that upon review of the patients evaluation and progress notes, the requested speech therapy is medically necessary for treatment of this patients autism spectrum disorder (ASD) and severe expressive and receptive language delays with socialization deficits. In the medical literature, the authors agree that language deficits are one of the core aspects of ASD, for which speech therapy provides professional help and guidance on communication development (Volmar and Weisner). The authors noted that language skills make a significant difference in the ability of children to control their environment.  Given the support provided in the scientific data, ongoing speech therapy is a medically necessary component of the treatment plan for this patient with ASD and should be approved.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested for pulmonary vein ablation for treatment of her atrial fibrillation. Findings:  Three physician reviewers found that while pulmonary vein ablation overall may not be a more effective treatment than standard medications, this patient has already failed medical therapy and continues to have limiting symptoms. Treatment with pulmonary vein ablation at this juncture is consistent with the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing.Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system. Mitotic index may also add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. A study reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma testing classification, in patients undergoing sentinel node sampling. However, it is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year data. Furthermore, it is not known if DecisionDx-Melanoma testing can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for Zembrace SymTouch pen injector. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Subcutaneous sumatriptan is highly effective for the acute treatment of migraine and has been approved by the U.S. Food and Drug Administration for this indication. The use of sumatriptan is medically necessary for the acute treatment of migraine when there are no medical contraindications. Zembrace has an easy-to-use self-injection system. Zembrace has been effective in this patients case. Therefore, Zembrace SymTouch pen injector services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Evidence based peer reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. A study concluded that hyaluronic acid (Orthovisc) was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Orthovisc injections have been found to be safe and effective, allowing delay of total knee replacement. In this case, the patient has been diagnosed with right knee osteoarthritis. Clinical examination findings were consistent with radiographic evidence of significant right knee tricompartmental osteoarthritis. Moreover, this patient has failed to adequately respond to other conservative treatment, including anti-inflammatory medications, physical therapy, and exercise. Prior viscosupplementation injections were performed with significant benefit allowing resumption of normal activities, including pain free running, and ability to avoid surgery. Therefore, Orthovisc injections are medically necessary for the treatment of this patients medical condition.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested for a positron emission tomography (PET) scan of the brain for evaluation her mediastinal mass.  Findings:  Two physician reviewers found that regardless of the PET results, this patient needs a tissue diagnosis to guide her care. Following a tissue diagnosis, a PET scan can be ordered for staging if appropriate. If the patient has a tissue diagnosis of malignancy, then PET would be an appropriate way to stage this patient and monitor her response to chemotherapy. If biopsy reveals infection or other benign findings, additional work-up may be required.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested subcutaneous hormone implantation for medical treatment of her menopausal symptoms.  Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists noted that there is a lack of evidence supporting compounded bioidentical hormones over conventional menopausal hormone therapy.  The potential risks of customized compounded hormones include variable purity and potency.  In addition to a lack of regulatory oversight, data on the efficacy, side effects, and long-term safety of bioidentical hormones are currently lacking.  All told, the requested subcutaneous hormone implantation was not likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The patient is requested authorization for Durolane injection in the left knee.Findings: Medical literature shows, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has patellofemoral pain in the left knee. The patient is trying physical therapy, with the alternative being a total knee arthroplasty. The patient has a history of relief from viscosupplementation in the right knee in 2016. Due to the similarity of the symptoms and findings of patellofemoral arthritis in the left knee, viscosupplementation injections are likely to provide relief. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Durolane injection in the left knee is medically necessary for the 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral cochlear implants for treatment of her bilateral profound sensorineural hearing loss post bilateral cochlear implants.Findings: The physician reviewer found that The records indicate the provider recommended replacement of this patients bilateral cochlear implants because the current sound processor is of an older generation and a new processor is available that has added features. This patient does have adequate cochlear implant on the contralateral side with the sound processor which appears to be functioning. Although the patients current sound processor is of an older generation, it remains partially functional and the cochlear implant on the contralateral side is indicated to be functioning. Thus, the request for replacement of the patients bilateral cochlear implants is not medically necessary for treatment of this patients sensorineural hearing loss.Final Result: The reviewer determined that the requested service 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 otolaryngology 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: An enrollee has requested authorization and coverage for advanced surface ablation (photorefractive keratectomy) for treatment of the enrollees blurry vision. Findings:  The physician reviewer found that hyperopia and astigmatism can develop following refractive surgery. Refractive surgery is an accepted treatment for hyperopic astigmatism. In this case, there is no evidence of medical contraindications to wearing glasses or contacts. Thus, refractive surgery is not indicated for this patient. Accordingly, the requested advanced surface ablation (photorefractory keratectomy) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 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.