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

A 46-year-old female enrollee has requested bilateral breast reduction surgery for treatment of her back, shoulder and neck pain secondary to macromastia. Findings:  The physician reviewer found that this patients condition may constitute an abnormal structure of the body however the documentation fails to establish that the patient has attempted and failed adequate conservative care. The patients photographs depict large breasts, but first-line treatment includes non-invasive therapies with medications such as non-steroidal anti-inflammatory drugs (NSAIDs), PT and supportive garments. This patients provider noted one month of PT. In general at least three months of PT is considered appropriate in order to fully address the patients issues. In addition, there is no evidence that the patient has undergone an adequate trial of supportive garments without improvement of her back, neck and shoulder symptoms. For these reasons, the requested surgery has not been established as medically necessary at this time, or reconstructive in nature, as first-line modalities have not reportedly been exhausted in this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Findings:  Three physician reviewers found the current medical evidence has not demonstrated the superior efficacy of the requested services over photon-based intensity modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Dosimetric studies have shown a benefit in bladder and rectal exposure with this regard. However, this does not appear to translate into actual decreased clinical side effect. Cancer control rates are also reportedly similar between photons and protons. National Comprehensive Cancer Network guidelines support the use of proton therapy as a reasonable alternative to x-ray based regimens at clinics with appropriate technology, physics, and clinical expertise, but with the caveat that no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. All told, the requested proton beam radiation therapy is not likely to be of greater benefit than other available treatment options.  Final Result: The reviewers determined that the requested services are 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 physician reviewers 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: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested rituximab (Rituxan) for treatment of her vasculitis.  Findings:  Three physician reviewers found that the patient has severe Sjogrens syndrome with an associated vasculitis. She has been treated with multiple immunosuppressive medications in the past but has been unable to tolerate them due to infectious and allergic complications. Long-term steroid therapy, although effective at reducing symptoms, is not practical due to significant cushingoid and other side effects.  The patients reported history of pancytopenia obviates the use of Cytoxan therapy, which would otherwise be considered standard therapy in a case such as this.  The RAVE trial (NEJM 2010) established the non-inferiority of Rituxan to Cytoxan for the induction of remission in ANCA-associated vasculitides. Although Sjogrens related vasculitis is not an ANCA-associated disease, case series and review articles published recently (Ramos-Casals and colleagues) establish anecdotal evidence for its efficacy in this condition. No large clinical trials exist for this specific condition (nor will they ever likely exist), so reliance on case series, anecdotal evidence, and extrapolation from large trials conducted in related diseases is important in making therapeutic decisions. Based upon the patients failed treatment history and the available evidence, Rituxan therapy is reasonable and indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism.   Findings:  The physician reviewer found that this patient has a diagnosis of autism with documented impairment in fine motor and self care tasks. He presents with cognitive/behavioral and sensory processing issues. The prevalence of impairments in fine/gross motor skills appears to be relatively high in autistic patients based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. Studies have shown that occupational therapy is beneficial in this setting in that it prevents deterioration and provides significant improvement in activities of daily living (Case-Smith and Arbesman, and Shoener, et al). As such, occupational therapy is within the standard of care for patients with autism and it is therefore medically necessary for this patient to receive the requested occupational therapy services.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parents of three-year-old male with expressive and receptive language delays are requesting reimbursement and prospective authorization of speech therapy.  Reviewers Findings:  The reviewing physician found that there is no evidence in the literature that the benefit derived from private therapy is greater than that provided in the school setting.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee requested valacyclovir for medical treatment of her medical condition.  Findings:  The physician reviewer found that this patient has documented recurrent herpes zoster.  Based on the description of her provider, she had recurrent rash as well as pain.  The current medical evidence supports the requested medication in this clinical setting.  Valacyclovir has been approved by the U.S. Food and Drug Administration for the treatment of this patients condition.  Because valacyclovir may be dosed less frequently, it is easier to use than acyclovir.  In this patients case, the requested medication is consistent with the usual standard of care.  All told, valacyclovir is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested bunionectomy procedures (28296 and 28310) and surgical shoes (L3260 x 2) for treatment of her bilateral hallux abductovalgus with bunion.  Findings:  The physician reviewer found that based on review of the available records, the patient has a bilateral moderate bunion deformity. Flex exam showed an increased intermetatarsal angle by 13 degrees, and a sesamoid position of 7 on the right, and 6 on the left. These radiographic findings are clinically consistent with the clinical findings of hallux abducto valgus. However, there is no documentation of failed conservative treatment options including alternative shoe gear, padding, anti-inflammatory treatments consisting of oral medications or local steroid injections, and orthotic therapy. A review of the literature indicates that when symptoms begin to interfere with a patients lifestyle, initial conservative treatment is often self-directed (i.e. lower heeled/wider shoes, bunion pads, ice, and over-the-counter analgesics). In addition, if the self-directed treatment fails and the patient is referred to a podiatrist, the patient should also undergo conservative treatment options before surgical correction is considered. Given the lack of documentation of adequate trials of self-directed treatment and provider recommended conservative measures, the requested services have not been established as medically necessary in this patients care at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia service. Findings: The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. The study concluded, Use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. In this case, the patient underwent a colonoscopy. He did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no history of difficulties with anesthesia or sedation with past colonoscopies in the documentation submitted. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 2 airway score, without evidence of a difficult airway. The literature does not support the use of anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the service at issue was not medically indicated. Therefore, anesthesia service was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 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 49-year-old male enrollee has requested for right knee surgery for treatment of his right knee pain.    Findings:  The physician reviewer found that the requested procedure is complex and requires special expertise. However, it is appropriate and necessary in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for the treatment of her depression. Findings:  Three physician reviewers found that VNS therapy remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research-centered, clinically-based and reproducible studies showing that VNS therapy is any better than sham treatment. VNS therapy is not a part of the established principles of health care practice for the management of refractory depression. VNS remains an experimental and unproven therapy at this time. It has not been accepted by the psychiatric community as routine treatment in the management of refractory depression.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Euflexxa injections. Per the medical literature, 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 such as the American Academy of Orthopedic Surgeons 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 tried and failed management with arthroscopic surgery and corticosteroid injections. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Euflexxa injections are 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast mastectomy with male chest reconstruction for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the documentation provided supports the requested procedure in this clinical setting. This patient has gender dysphoria and is transitioning to a male. This patient has evidence of abnormal breasts for a male despite the use of hormonal therapy. Additionally, this medical condition would not likely resolve with continued hormonal therapy. While the Health Plan criteria provides that the patient should be 18 prior to undergoing surgical intervention, chronological age is not as important as the level of pubertal development. In this patients case, his breasts appear to be consistent with a teenage female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  In sum, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral breast mastectomy with male chest reconstruction is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested surgery is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. According to the definition and significance of gender dysphoria, abnormal breasts can be considered a developmental abnormality in a male. Reconstructive surgery in this clinical setting is generally performed to improve function, but may also be performed to approximate a normal appearance. In this patients case, the breasts should be more consistent with male breasts. Based on the patients gender dysphoria and his identification as a male, a normal appearance of the breasts for a male is the ultimate goal. In this patients case, he has evidence of abnormal breasts for a male. The goal of the surgery is to create a more normal appearing male chest and offer a more than minimal improvement in the appearance of this patient. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 20-year-old female enrollee has requested for residential treatment services  for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that there was no medical necessity for a residential treatment center admission for this patient. Only outpatient treatment had been tried. No intensive outpatient or partial hospitalization program had been attempted. The patients weight was very near 100% of ideal body weight, and she had no compromise in her medical/psychiatric condition necessitating a 24-hour, structured, interdisciplinary milieu.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The parent of the enrollee has requested authorization and coverage for genetic testing (Fragile X DNA analysis and ID Next) for evaluation of the enrollees autism spectrum disorder.Findings: Two physician reviewers found that the American Academy of Pediatrics has issued guidelines specifying that any child with global developmental delay or isolated speech/language delay of unknown cause be tested for Fragile X syndrome as a first tier evaluation. The American College of Medical Genetics has also published practice guidelines that call for the testing of Fragile X syndrome in individuals with autism. Therefore, Fragile X DNA testing is the standard of care and is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. However, there is a lack of published data in the peer-reviewed literature supporting the clinical utility of ID Next or other intellectual disability gene panels.Final Result: The reviewers determined that a portion of the requested testing is 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 pediatrics and clinical genetics 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

A 60-year-old female has requested coverage for wheelchair rental for her status post right fibula fracture and ankle dislocation.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the equipment at issue.  As noted by Davidovitch and colleagues, ankle fractures that are surgically repaired have a good functional prognosis, including in the relatively elderly.  There are no indications in the present case that the patient did not have a good functional outcome following her surgical repair.  The submitted documentation does not demonstrate that the patient had ongoing impairments, limitations or restrictions that required the use of a manual wheelchair during the time period under review.  There are no indications that the wheelchair was recommended or prescribed by any of the patients providers during this time period.  By self-report, the patient was working, and she was not using the wheelchair during the day while at work.  She did not undergo the hardware removal surgery until after this time period.  All told, the wheelchair rental at issue was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 71-year-old female enrollee has requested injectable methotrexate for treatment of her lupus anti-coagulant-type syndrome. Findings:  Three physician reviewers found that per the relevant literature, methotrexate is an appropriate treatment for undifferentiated connective tissue disease. The patient has achieved good results with methotrexate, but is unable to tolerate the oral form of the medication. Therefore, injectable methotrexate is clinically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the DecisionDx-Melanoma gene test. This patients dermatopathology report demonstrated melanoma with a Breslow depth, non-ulcerated, stage pT2a. He underwent DecisionDx-Melanoma gene testing to assist in his treatment planning. The DecisionDx-Melanoma gene test analyzes the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The National Comprehensive Cancer Network (NCCN) guidelines do not endorse routine use of the DecisionDx-Melanoma gene test. Overall, there is a lack of published data to support its routine use in this clinical setting. All told, the DecisionDx-Melanoma gene test was not likely to be more beneficial for evaluation of the patients 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 reviewers 1, 2, and 3 are board certified in dermatology 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.