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

A 60-year-old female enrollee has requested Gamma Knife radiosurgery for treatment of metastatic brain lesions.  Findings:  The physician reviewer found that there is no question that radiosurgery is a powerful tool in the delivery of localized radiation to a solitary brain tumor. However, evidence of efficacy is lacking in the setting of multiple intracranial metastases. Radiosurgery is also effective as a boost to the dominate mass following whole-brain irradiation and results are superior to whole-brain irradiation alone. Gamma Knife radiosurgery may also be appropriate in the event of an intracranial recurrence. However, whole-brain irradiation, in conjunction with recommended systemic therapies, is standard of care for a patient such as this patient. Treatment with radiosurgery alone to avoid the toxicity of whole-brain irradiation is to invite the toxicity associated with a growing intracranial tumor.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a positron emission tomography (PET) scan performed for evaluation of the enrollees chest pain. Findings:  The physician reviewer found that although solid or ground glass nodules are of greater concern for malignancy than round solid nodules, the use of PET imaging in a nodule under 8-10 mm in diameter is not indicated as the resolution capability of the technique in such a small nodule is limited. As recommended for surveillance of pulmonary nodules, PET should be considered if the incidental nodule exceeds 10 mm in diameter. Based upon these published guidelines, the PET scan performed was not medically necessary for evaluation of this patients semi solid nodule measuring 4 x 5 mm. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female who had spinal fusion and instrumentation in 2001 for severe scoliosis. She experienced neck and shoulder pain in November 2004 and was treated by her primary care physician with Toradol, tramadol, and Medrol dose pack. She now complains of increased pain and sensory deficits. Spinal x-rays were negative for any acute abnormality. The patient believes she should only be treated by her previous surgeon (or his associate) and is requesting an immediate spinal CT.  The Health Plan denied both of these requests based upon their determination that neither an out-of-network physician referral nor a spinal CT are medically necessary at this time.  The patient would clearly benefit from an orthopedic surgery consultation. The Health Plan indicates the services of an orthopedic surgeon are available within the Health Plans provider network. As long as the orthopedist specializes in spinal disorders and performs the type of surgery the patient underwent years ago, the patient can be appropriately treated by the in-network provider. No evidence has been provided that demonstrates a need for the patient to be seen by her previous surgical group.  As such, it is not necessary that she see the requested out-of-network physician. With regard to the CT scan, the evaluating physician can order this test if it is deemed necessary. It is not indicated at this time.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries.  The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges that, although facial feminization procedures are generally labeled aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. The WPATH supports facial feminization surgery and breast augmentation as medically necessary for the treatment of a patients gender dysphoria. The purpose of medically necessary facial feminization surgery is to relieve gender dysphoria, which the surgery does through harmonization with regard to other modified structures...achieving an aesthetic result beyond gender difference. Researchers demonstrated that facial feminization surgery, similar to genital surgery, improved mental health related quality of life. This patient meets the WPATH criteria for gender dysphoria to support an indication for facial feminization surgery and breast augmentation. This is based upon clinical documentation of persistent gender dysphoria related to masculine facial and body features associated with clinically significant symptoms of depression. Given the WPATH support for the requested procedures, the requested facial feminization surgeries are 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

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old male enrollee has authorization and coverage for testosterone cypionate 200 mg/mL. Findings:  The physician reviewer found that masculinizing therapy for female to male transgender patients consists primarily of testosterone therapy. The Endocrine Society has recognized that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years. The Endocrine Society recommends treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. This patient meets the criteria for continued treatment with testosterone therapy. The records document the patient has been living as an authentic male for more than nine years and has been treated for a diagnosis of gender dysphoria for seven years. The patient started puberty suppression in 2013 and has been treated with testosterone for three years. The provider reports the patient has demonstrated a greatly improved quality of life since starting treatment with testosterone therapy. Given these findings, the requested testosterone cypionate 200 mg/mL is medically necessary for treatment of this patients gender dysphoria. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 male enrollee requested readmission and treatment including physical and occupational therapy for treatment of his difficulty walking, unspecified essential hypertension, and cellulitis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient did not sustain any lower body injuries.  He underwent inpatient rehabilitation for a rotator cuff repair that was complicated by a contralateral upper limb deep vein thrombosis and pulmonary embolus.  Further care could have been provided in the community setting with caregiver assistance and home health services.  His warfarin anticoagulation could have been followed as an outpatient, as planned by the treating providers.  Given that further care could be provided at a less intensive setting, readmission and treatment including physical and occupational therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Mohs micrographic surgery for treatment of the patients medical condition. Findings:  The physician reviewer found that As noted in the medical literature, squamous cell carcinoma of the lower extremity can be excised with simple excision. However, this patients case is an exception based on the location and resistance to previous treatment. Current data supports an indication for Mohs surgery in this clinical setting. Nouri noted that Mohs micrographic surgery can be effective despite the variability in time interval between the initial biopsy and surgery. Given these findings, Mohs micrographic surgery is medically necessary to assure a complete excision of this patients lower extremity squamous cell carcinoma.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 dermatology 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 23-year-old male enrollee has requested eating disorder partial hospitalization program services (PHP) for the treatment of his condition. Findings:  The physician reviewer found that the APA guidelines state that outcomes from partial hospitalization programs that specialize in eating disorders are highly correlated with treatment intensity. The more successful programs involve patients in treatment at least 5 days per week for 8 hours per day. Thus, it is recommended that partial hospitalization programs be structured to provide at least this level of care. The aims of treatment for patients with bulimia nervosa are to 1) reduce and, where possible, eliminate binge eating and purging; 2) treat physical complications of bulimia nervosa; 3) enhance patients motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse. For this patient the PHP program was effective in reducing purging, but did not eliminate such.  There were no significant clinical complications.  Cooperation and motivation improved, and education was provided.  The core problems include a personality disorder that will be difficult to change.  The psychiatric comorbid conditions are being treated with a need to re-evaluate psychopharmacological intervention.  The family is now actively involved to reduce the symbiosis that they have with their son.  Relapse prevention can be addressed at a lesser level of care after the patient is stabilized at the PHP and seen an average of 5 days per week over the above stated period of time.  Admitting the patient for a 7 days per week program initially with reduction as stated offers the intensive treatment that is suggested in the APA guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the ReWalk Personal 6.0 Lower Extremity Robotic Exoskeleton.Findings:  Three physician reviewers found there is a lack of support for the requested device in this clinical setting. The published evidence indicates that powered exoskeletal devices aimed at enabling upright ambulation in persons with paraplegia are not an efficient, reliable or practical means of mobility for this population. This type of device is associated with high feasibility challenges. There are multiple risks associated with use of this device as a mobility device outside of very controlled environments, such as a physical therapy gym, including, but not limited to, the risk of fall, risk of becoming stranded (due to mechanical failure, loss of power, etc.), and risk of the potentially serious, adverse health-related sequelae associated with these events. This increased exposure to potential adverse sequelae is unnecessary given that a much more established, reliable, efficient and safe means of mobility is readily available, such as a manual wheelchair.There is a lack of proven health benefit of standing and intermittent passive walking using an externally powered exoskeleton to passively move the lower limbs.  Standard of care for achieving appropriate levels of cardiovascular and musculoskeletal exercise in the setting of this patients condition would be performing regular physical activity using volitionally active musculature, including, but not limited to, propulsion of a manual wheelchair, wheelchair sports and other adaptive sports/exercise activities. There is no expected marginally significant health benefit of standing and ambulation using an externally powered exoskeletal device over natural, self-powered activity and exercise.  While there are potential benefits of use of this type of device with respect to bone or soft tissue health, there is as yet no proven benefit of use of this type of device with respect to any clinically-significant outcomes. The available, published data are scarce and low quality. In sum, the ReWalk Personal 6.0 Lower Extremity Robotic Exoskeleton is not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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 Harvoni for treatment of her medical condition.   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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: An enrollee has requested authorization and coverage for lumbar spinal fusion for treatment of the enrollees spondylolisthesis. Findings:  The physician reviewer found that evidence based medical guidelines support lumbar spine fusion for isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Fusion be considered for patients with low back pain and isthmic spondylolisthesis who have failed non-operative treatment. The peer-reviewed literature supports lumbar fusion in the setting of isthmic spondylolisthesis with symptomatic radiculopathy or spinal stenosis when non-operative treatment has failed. This patient presented with a history of chronic low back pain radiating to the right buttock and left leg. There is imaging evidence of isthmic spondylolisthesis at L5/S1 with moderate lateral recess and foraminal stenosis. Evidence of long-term reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Therefore, the requested lumbar spinal fusion is medically necessary for the treatment of this patient. Final Result: The reviewer determined that I have determined that the requested procedure 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 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: The patient has requested authorization and coverage for Cosentyx 150 mg/mL Sensoready pen. The records provided for review document that this patient presents with a history of moderate-to-severe plaque psoriasis. The patients provider has recommended treatment with Cosentyx. Systemic treatment of psoriasis is indicated when topical treatments fail or do not achieve  sufficient control of disease. The available clinic notes adequately document that the patient has failed treatment with topical therapies, which supports an indication for systemic treatment. The U.S. Food and Drug Administration (FDA) has approved several systemic options for patients with moderate-to-severe psoriasis including non-biologics and biologics such as tumor necrosis factor (TNF)-alpha inhibitors, IL-17 pathway inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors. Medical literatures reported that biologics have been found to be more effective than the non-biologic alternatives. However, there is a lack of data demonstrating that any of the IL-17 or IL-23 inhibitors is more effective than another. The patients provider did not chart support for Cosentyx in lieu of other IL-17 or IL-23 agents. Therefore, the requested Cosentyx 150 mg/mL Sensoready pen 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 dermatology 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 enrollee is requesting authorization and coverage for vest airway clearance system. The enrollee has a history of pulmonary fibrosis, bronchiectasis, and chronic obstructive pulmonary disease. He requires chest physical therapy to clear secretions and currently does not have a caregiver to perform it. The enrollees advocate reports consistent, aggressive airway clearance is necessary for the enrollee to maintain his pulmonary function. Retention of secretions can lead to chronic inflammation and progressive lung damage, with the possibility of developing resistance to standard treatment. Medical records did not demonstrate this enrollee had a continuous, productive cough for more than six months. Records do not demonstrate that this enrollee experienced frequent exacerbations, more than two, in the last year which required treatment with anti-infective medications. This enrollee was not described as having copious, difficult-to-expectorate sputum. Records indicate the enrollee demonstrated mostly clear secretions, which were triggered by allergies. The records do not support more than two exacerbations, as defined by literature, over a period of one year, which would support more aggressive management. An expert consensus in the management of bronchiectasis due to various etiologies reports that, for children and adults with a productive cough due to bronchiectasis from any cause, the recommendation is for teaching airway clearance techniques by professionals with advanced training in airway clearance techniques.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pulmonary disease 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.