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

The patient has requested authorization and coverage for facial feminization surgeries. The World Professional Association for Transgender Health (WPATH) acknowledges that, For certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. In addition, WPATH further noted that, Other surgeries for assisting in body feminization includerhinoplastyfacial bone reduction, face-lift, and blepharoplasty. Researchers demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life in patients with gender dysphoria. This patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based on clinical documentation of persistent gender dysphoria related to masculine facial features associated with distress. All told, 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

A 23-year-old male enrollee has requested a functional/de-rotational anterior cruciate ligament (ACL) knee brace for treatment of his knee status post ACL repair surgery. Findings:  The physician reviewer found that an active 23-year-old patient is likely to benefit from the protective effect of his treating physicians prescription for a functional de-rotational ACL knee brace. This patient was noted to have an unstable lateral meniscus tear, which the provider specifically addressed with use of a functional, de-rotational brace, to prevent re-injury with activity several months after surgery. It was therefore in the best interest of this patient to be fitted for and use the knee orthotic recommended by his treating physician. For these reasons, the device at issue was medically indicated and appropriate for post-operative management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old male with prostate adenocarcinoma. In September 2004, a prostate biopsy revealed Gleason 3+3=6 adenocarcinoma on the left side of the prostate gland. In October 2004, a bone scan was negative for metastatic disease. In May 2005, a repeat prostate biopsy revealed Gleason 3+3=6 adenocarcinoma of the left side of the prostate gland at the apex and mid-gland. In July 2005, a CT scan of the pelvis revealed prostatic enlargement with calcification. The patient elected to proceed with proton beam therapy. The Health Plan had recommended alternative treatment including external beam radiation therapy, brachytherapy, and radical prostatectomy. The Health Plan has denied reimbursement for the proton beam therapy.Based upon the patients relatively low PSA  ranging from 2.3 to 5.6  the cancer appears to be localized to the prostate gland itself representing a potentially curable cancer. The patient chose to proceed with proton beam therapy. The Health Plan offered the patient appropriate alternative treatments. Based upon current peer-reviewed literature, there are no randomized controlled trials demonstrating proton beam therapy is superior to other forms of conformal external beam radiation therapy. Therefore, because the Health Plan offered the patient appropriate treatment alternatives, there is no evidence that proton beam therapy was medically necessary for this patient. As such, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested a referral for acupuncture treatment for treatment of his carpal tunnel syndrome.  Findings:  The physician reviewer found that in this patients case, the current medical evidence does not support the medical necessity of the requested service. The value of acupuncture therapy in the treatment of carpal tunnel syndrome has been the subject of study. Although some reports have been encouraging, most other reports have not. Significant benefit was not seen in studies, and other reviews have not suggested that this treatment is effective.  More recent trials have not established a therapeutic value for acupuncture in the treatment of carpal tunnel syndrome, and further trials were recommended by Sim and colleagues.  Other studies in progress have not yet published their results.  At this time, the current medical literature has not demonstrated the efficacy of the requested service in this clinical scenario.  All told, the requested referral for acupuncture treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old female has requested revision of the scars resulting from suture ligation of accessory digits. The patient has been seen and evaluated by a plastic surgeon. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is cosmetic and therefore, not medically necessary. The records provided include a referral from the patients primary care physician and the consultative note of the plastic surgeon. No photographic evidence has been provided. These records do not document evidence of any functional deficiency. The patient has scar tissue on the ulnar side of the fifth digits bilaterally, which would be expected with removal of the extra digits. There is no documentation supporting the medical necessity of the requested procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old female enrollee has requested cognitive rehabilitation (code 97532) for treatment of the enrollee, who is status post status epilepticus with resultant cognitive delay.  Findings:  Three physician reviewers found that in this patients case, cognitive rehabilitation is likely to be the most beneficial treatment for this patient. At issue is the notion that plasticity in the developing brain exists and can be utilized to improve overall neurologic health.  Thus, specific treatment, including cognitive therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process.  Given that the patients neurodevelopmental status was normal prior to the onset of her refractory seizures, cognitive rehabilitation may help her achieve independence in her activities of daily living by fully utilizing brain circuitry not affected during her status epilepticus.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid 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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 62-year-old woman with multiple significant risk factors for coronary artery disease including hyperlipidemia, obesity, previous stroke at age 59, and hypertension. The patient presented to her primary care physician and complained of chest pain, which was described as 5 to 6 out of 10 and as lasting for a few seconds. The patient has also experienced a recent onset of fatigue and shortness of breath. She wishes to be evaluated by a cardiologist. The Health Plan has denied authorization and coverage for a referral to a cardiologist on the basis that the requested referral is not medically necessary for treatment of the patients medical condition.The patient has multiple risk factors for coronary artery disease and has a significantly higher pretest probability of having coronary artery disease based upon her risk factors and an earlier than expected presumed cerebral atherosclerotic event. This patient has been referred by her primary care physician to cardiology services, which is an appropriate referral given the patients symptoms and significant risk factors. Based upon the submitted information, a cardiology consultation for evaluation of chest discomfort to rule out significant coronary artery disease is medically reasonable and constitutes an appropriate use of cardiology services. Therefore, I have determined that the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a DOC Band cranial remolding orthotic device. Laughlin and colleagues found that positional skull deformities may be present at birth or may develop during the first few months of life and are generally benign and reversible. The authors recommended positioning and observation for mild-to-moderate deformity, noting that cranial orthoses should be reserved for severe cases of deformity or for the infant whose deformity does not improve after six months of age. Tamber and colleagues found, There is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. In a randomized controlled trial of helmet therapy in 84 infants with positional skull deformation, Van Wijk and colleagues concluded, Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation. In this case, the documentation provided reflected that the patients positional plagiocephaly was moderate. Given that current medical literature does not support the use of a cranial helmet in moderate cases of positional plagiocephaly, the requested equipment is not medically indicated. Therefore, a DOC Band cranial remolding orthotic device is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 neurology with special qualification in child 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 hyaluronan injections (Synvisc or Euflexxa) in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history of good lasting benefit from multiple prior injections since 2013. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, hyaluronan injections (Synvisc or Euflexxa) in both knees are medically necessary for the treatment of the 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy services. Researchers note that ovarian cancers often present in advanced stages of disease due to a relative absence of symptoms during earlier stages. Researchers note that  peritoneal carcinomatosis are difficult to treat, with recurrences frequently observed, leading to a poor prognosis. Researchers note that management around advanced peritoneal carcinomatosis  revolve around palliation of symptoms and providing support and resources to address emotional and existential concerns. In this case, the patient has ovarian cancer. She benefitted from initial physical therapy. She was discharged from physical therapy services due to having achieved therapy goals that included independent transfers and household level mobility with a walker. While she continued to have mobility deficits, the documentation does not support the necessity of additional physical therapy to improve her clinical course or outcomes. Therefore, physical therapy services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for authorization and coverage for a Nalu Neurostimulation System. In a systematic review of 14 randomized control trials, researchers reported moderate to strong evidence supporting the use of peripheral nerve stimulation (PNS) to treat pain, including in the sural, superficial peroneal, and lateral femoral cutaneous nerves. In a review of the bioelectrical implications of stimulation of the PNS for chronic pain conditions, researchers noted that PNS utilization produced consistently high success rates in achieving pain relief in well selected patients when delivered by skilled clinicians. In this case, the patient has a history of chronic left shoulder pain and has failed conservative treatment, including physical therapy, chiropractic care, behavior modification, transcutaneous electrical nerve stimulation (TENS) therapy and psychiatry. Visit notes reported that the patient had failed medication management with nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, along with interventions such as suprascapular nerve blocks. The records noted that the patient reported success with a PNS trial. In this clinical setting, the current medical literature supports the use of PNS as superior to conservative therapy, which has already been tried and failed. Therefore, a Nalu Neurostimulation System is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Nalu Neurostimulation System is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right shoulder and right shoulder arthroscopy, open reduction with internal fixation (ORIF) surgery. The American College of Radiology (ACR) guidelines do not recommend MRI for the evaluation of traumatic shoulder pain when radiographs show humeral head or neck fracture. Steinhaus and colleagues discussed the complex treatment of displaced proximal humerus fractures, as its success is predicated on multiple factors. The authors noted that the majority of proximal humerus fractures may be treated non-operatively, and studies have not established which patients will benefit from surgical management. Howard and colleagues evaluated three randomized controlled trials and concluded that the available data have not demonstrated a difference in patient-centered outcomes when comparing non-operative treatment with ORIF surgery. This patient presents with a history of right humeral fracture due to a fall from a bicycle. Initial x-rays demonstrated fracture of right humeral greater tuberosity, slight displacement present, and good alignment. Initial evaluation recommended activity modification, sling immobilization, and medications. The patients provider has recommended right shoulder MRI and right shoulder arthroscopy, ORIF. However, the medical records do not support an indication for the requested MRI and surgery. Current evidence-based medical literature does not support the use of MRI for the evaluation of traumatic shoulder pain when radiographs demonstrate humeral head or neck fracture, as in this patients case. Overall, conservative treatment is recommended over surgical management of patients with proximal humeral fractures. This patients records do not provide a compelling rationale or extenuating circumstances to support the medical necessity of this request as an exception to literature recommendations. Therefore, the requested MRI of the right shoulder and right shoulder arthroscopy, ORIF surgery are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 Dapsone for treatment of his medical condition. Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  Per the medical literature, there are numerous topical and systemic therapies which are available for the treatment of psoriasis.  Treatment modalities are chosen on the basis of disease severity, relevant comorbidities, efficacy, and evaluation of individual patient response. It is recommended that patients with mild to moderate plaque psoriasis be initially treated with topical corticosteroids and emollients. Combination regimens may be required, including localized phototherapy.  Most patients with moderate to severe plaque psoriasis should be initially treated with phototherapy if feasible. In this case, the patient has a diagnosis of psoriasis.  Dapsone is not a medication indicated in first-line treatment for this condition.  All told, Dapsone is not medically indicated for the 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 internal 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: Upheld

The parent of a three-year-old male enrollee has requested a circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that phimosis is defined as the inability to retract the penile foreskin. Initially, in the uncircumcised infant, this is physiologic. Over time, if it persists, it may become pathologic in the presence of inflammation or scar tissue. Initial treatment involves application of corticosteroid cream. In the event of phimosis beyond age 10 years of age, failure of steroid treatment, or ballooning of the foreskin with urination, circumcision is indicated.  According to a recent study by Zavras and colleagues of 1185 boys with a diagnosis of phimosis (some with mild balanitis), treatment with topical steroids was successful in 91% of cases.  This patient has symptomatic phimosis, and the literature supports the safety and efficacy of a course of topical steroids prior to surgical intervention. Thus, circumcision is not medically indicated for the treatment of this patient at this time.