Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for nitric oxide expired gas determination (CPT 95012). Findings:  The physician reviewer found that the records provided for review do not include documentation poorly controlled asthma or multiple emergency department visits or hospitalizations which are suggestive of poor control. Moreover, there is a paucity of medical literature or clinical guidelines to support a role for nitric oxide expired gas analysis to determine airway inflammation in this patient. van Mastrigt and colleagues found that that analysis of volatile organic compounds in exhaled breath is still a research tool and not validated for clinical use. Hence, the nitric oxide expired gas determination (CPT 95012) was 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 nitric oxide expired gas determination (CPT 95012) was 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in medical toxicology and pediatric pulmonology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease 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

Standard Review A transgender female enrollee has requested authorization and coverage for facial feminization surgeries (craniofacial coronal reconstruction with hydroxyapatite (HA) cement, osteoplasty of facial bone reduction of mandibular angles, rhinoplasty major, neck liposuction, upper lip shortening and lowering of the hairline). The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for the treatment of the enrollees gender dysphoria. Credentials/Qualifications: The reviewer is board certified in plastic 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. Nature of Statutory Criteria/Case Summary: Based on the entirety of the medical documentation provided for this review, the requested procedures are not medically necessary. The patient is well-documented to have gender dysphoria. Thus, her external anatomy should be more consistent with a female than a male. The patient is noted to have undergone gender reassignment surgery and has been on hormonal therapy for over 20 years. However, in the records provided, there is a lack of documentation that the patient presents with masculine facial features that require surgical treatment. A detailed examination is lacking in the medical records provided for review. In addition, the photographs do not show evidence of a clearly masculine appearance of the brows, forehead, neck, lip and facial bones. Instead, the photographs are more consistent with a female appearance with signs of facial aging.  These findings are gender neutral and not atypical for a female appearance. As such, the documentation provided does not establish the medical necessity of the requested services for treatment of this patient. Therefore, facial feminization surgeries (craniofacial coronal reconstruction with HA cement, osteoplasty of facial bone reduction of mandibular angles, rhinoplasty major, neck liposuction, upper lip shortening and lowering of the hairline) are not medically necessary for the treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation does not demonstrate that the patients condition constitutes an abnormal body structure. As stated and reasoned above, the requested facial feminization surgeries are more consistent with aesthetic improvement, addressing appearance concerns and not specific to gender related abnormalities. Thus, this patients facial presentation does not constitute an abnormal body structure. Therefore, the requested services are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) oxycodone-acetaminophen 10-325 mg (30 tablets for a 15-day supply), and (2) oxycodone-acetaminophen 10-325 mg to be filled for a 30-day supply. The Washington Agency Medical Directors Group guidance on prescribing opioids postoperatively recommends prescribing the lowest effective dose strength in cases of severe pain for 14 days or less. The authors note that for exceptional cases warranting more than 14 days of opioid treatment, the surgeon should reevaluate the patient before refilling the prescription and taper the patient off opioids within six weeks after surgery. On determining when to initiate or continue opioids for chronic pain, researchers report, 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. In this case, the patient was prescribed oxycodone-acetaminophen for fifteen days for acute pain from facial laceration, contusions of the abdomen and chest wall, closed head injury, and pain in the neck, right hip, and right shoulder following a motor vehicle accident. While the provider performed a CURES review and noted no aberrant behavior, the patient reported self-prescribing behavior with alcohol in his application for independent medical review. Current medical guidelines note that initial prescriptions for opioids may be medically necessary for the treatment of acute pain; however, continuation of opioid therapy is not recommended without a reevaluation by the treating provider and in cases where the risks may outweigh the benefits. Therefore, (1) oxycodone-acetaminophen 10-325 mg (30 tablets for a 15-day supply) was medically necessary for the treatment of this patient, and (2) oxycodone-acetaminophen 10-325 mg to be filled for a 30-day supply is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and is partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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

The patient has requested authorization and coverage for revision of previous bariatric surgery (gastric bypass) excluding lap band. Researchers reported the evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. The authors also reported that purse-string transoral outlet reduction (TORe) to treat weight regain after RYGB is technically feasible and safe. Additionally, it is associated with improvement in weight and comorbidity profiles up to 12-months post-procedure. In this case, the patient has experienced weight regain after a RYGB procedure with co-morbidities including type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux disease. The provider also noted an upper gastrointestinal imaging revealed that the patients stoma was greater than two centimeters, indicating dilation. The medical evidence supports the requested service in this clinical setting. Therefore, revision of previous bariatric surgery (gastric bypass) excluding lap band is medically necessary for the treatment of this patient. 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 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: Upheld

The parent of is a four-year-old male who was diagnosed with hypotonicity and motor apraxia is requesting reimbursement for occupational therapy (OT) services.  Reviewers Findings:  The reviewing physician found that the OT services were not medically necessary or reasonable because the foundational program could have been accomplished in a home setting without expert OT supervision or oversight.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy services (provided in the home) at a frequency of two times per week, occupational therapy services (provided in the home) at a frequency of two times per week and physical therapy services (provided in the home) at a frequency of two times per week for the enrollees  Down syndrome.  Findings:  The physician reviewer found that twice weekly speech therapy services are medically necessary to address this patients delays in speech and language skills and feeding skills.  Many children with Down syndrome have cognitive deficits as well as difficulty with speech. Speech intelligibility, in particular, is a significant and prominent problem. Children with global developmental delay, such as those with Down syndrome, are also at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information. It is important to aggressively and thoroughly address their deficits to prevent further impact on growth and development.   This patient has made progress with speech and language therapy. Aggressive work in oral motor strength and control as well as tongue positioning will lay the groundwork for improvement in her ability to communicate. Twice weekly occupational therapy services are medically necessary to address this patients delays in fine motor skills and feeding skills.  She has delays in fine motor skills, self-help skills, and feeding skills. Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients.  In addition, with its focus on developing self-help skills, including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patients case. Twice weekly physical therapy is medically necessary to address this patients delays in gross motor skills.  She has gross motor delays in both stationary and locomotion skills, with challenges in ambulation, jumping, balance, posture, and shifting weight. She has made gains in all areas, with improved ability to transition from stand to sit and climb stairs. Twice weekly physical therapy is medically necessary and will allow this patient to continue to improve and safely navigate through her environment. All told, speech therapy services at a frequency of two times per week, occupational therapy services at a frequency of two times per week and physical therapy services at a frequency of two times per week are medically indicated.  However, it is not necessary that these services be provided in the home.  In the absence of immunodeficiency that would make going to an institution hazardous, in-home therapy would not be medically necessary.  The medical records do not indicate that this patient is immunocompromised.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Botox injections. This enrollee has chronic low back pain as the result of several car accidents. He has had injections and surgery but his symptoms are still present. He currently uses pain medications, including Tylenol and OxyContin. His physician is requesting Botox injections. Botox injection has been shown to help with piriformis muscle syndrome. Studies show pain improvement persists twelve weeks after injection.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old female has requested authorization the Minimed Paradigm Real Time continuing glucose monitoring system for treatment of diabetes.  Findings:  Three physician reviewers found that since their inception several years ago, continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypo and hyperglycemia in insulin treated patients who are not in good control. Recent reports indicate that continuous glucose monitoring for up to three months results in improvement in A1c levels as well as in detecting unexpected hypo and hyperglycemia.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that despite the lack of long-term results proving an increased survival rate when tomosynthesis has been used in addition to two-dimensional (2D) imaging, the American College of Radiology (ACR) has urged the technique be removed from the investigational due to the advantages it brings to radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks, increase in accuracy and increase in detection of small cancers. Thus the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her exam been done with 2D technique. Given that her screening exam included tomosynthesis, spot compression views using a standard approach would have yielded the same information.  For this reason the inclusion of tomosynthesis as part of the unilateral diagnostic study performed subsequent to the initial screening exam was not likely to have been of greater benefit to the patient than conventional work-up.  Final Result: Two reviewers determined that a portion 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 partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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

A 51-year-old female enrollee has requested for magnetic resonance imaging of the left foot and leg for evaluation of her left foot pain.  Findings:  The physician reviewer found that this patient has been evaluated with an MRI without evidence of pathology. The records are absent documentation of any trauma or signs of infection. In addition, the patients pain is lateral in distribution, but the posterior tibialis tendon is a more medial structure. The provider has not reported any point tenderness over the patients proximal posterior tibialis tendon to warrant further investigation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the tumor treatment field (TTF) therapy (with Optune Plus transducers, CPT code E0766). According to the current National Comprehensive Cancer Network (NCCN) guidelines for the adjuvant treatment of glioblastoma, TTF therapy has a category 1 recommendation only for patients with supratentorial disease, as in this patients case. In addition, a large multi-institutional prospective controlled trial randomized recurrent glioblastoma patients to receive chemotherapy or treatment with the Optune device. The authors concluded that efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma. Toxicity and quality of life clearly favoured TTF. As this patient has already been treated with chemotherapy and radiation, the requested addition of the TTF therapy with Optune Plus transducers, CPT code E0766, is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the TTF therapy with Optune Plus transducers, CPT code E0766, is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that TTF therapy with Optune Plus transducers, CPT code E0766, is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for nasal/sinus endoscopy  along with the approved submucous resection inferior turbinate, partial or complete, any method and septoplasty or submucous resection, with or without cartilage scouring, contouring or replacement with graft. Findings:  The physician reviewer found that while chronic rhinosinusitis is often successfully managed in the primary care setting using antibiotics, topical or oral steroids, and saline nasal irrigation, surgery is an option when medical management fails.  In this case, the patient has a history of allergies and sinus infections, but the records do not reflect chronic sinusitis, which is defined as twelve consecutive weeks of symptoms, or recurrent acute sinusitis, requiring four or more provider visits in a year. The records do not reflect the patient has been evaluated or treated for allergies or migraines, which may cause recurrent or chronic sinus headaches. While a CT scan reported abnormal findings, it showed normal mucosa of the maxillary sinuses and an open ostiomeatal complex. Septal deviation is present in the majority of the population and is not an indication for surgery. Given that the records do not reflect chronic or recurrent sinusitis, the requested service is not medically indicated. Therefore, nasal/sinus endoscopy along with the approved submucous resection inferior turbinate, partial or complete, any method  and septoplasty or submucous resection, with or without cartilage scouring, contouring or replacement with graft is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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  head and neck 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

A 55-year-old female enrollee has requested silicone injection into her left heel for the treatment of her left heel pain. Findings:  The physician reviewer found that silicone injections are currently under clinical investigation for heel fractures. At this time, there is no peer-reviewed evidence demonstrating that silicone injections are effective for the treatment of heel pain status post heel fracture. Nor is there adequate data to determine the safety of the proposed silicone injections. In the past, silicone injections have been shown to cause serious liver problems. The use of silicone injection post heel fracture is not generally accepted as standard treatment in this setting, and as such, is not indicated for this patient. Other modalities are available in this setting, such as the use of silicone pads.