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

A 73-year-old female enrollee has requested hydroquinone 4% cream for treatment of her post-inflammatory hyperpigmentation. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient developed post-inflammatory hyperpigmentation following an epidural steroid injection.  Post-inflammatory hyperpigmentation is due to the deposition of pigment in the papillary or mid-dermis.  Hydroquinone is a topical depigmenting agent that is useful for epidermal pigmentation, like melasma.  Hydroquinone is generally ineffective for the treatment of post-inflammatory hyperpigmentation as it does not penetrate to the appropriate depth in the skin.  Therefore, the requested hydroquinone 4% cream is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lumbar total disc arthroplasty (CPT codes 63077, 63078, 22857 and 0163T). The submitted documentation supports the medical necessity of the requested service. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease. The FDA further notes that the patient should have no more than grade 1 spondylolisthesis at the involved level and have failed at least six months of conservative treatment. The FDA notes that contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. The 2020 updated FDA guidance now provides for multilevel (2) disc replacement in the setting of degenerative disc disease. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, Zigler and colleagues noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for lumbar arthralgia and lumbar radiculopathy and reports persistent and ongoing pain. Diagnostic imaging corroborates multilevel degenerative changes with plausible pain generators. Given the current FDA guidance, the requested service is medically indicated in this clinical setting of multilevel degenerative disc disease. Therefore, a lumbar total disc arthroplasty (CPT codes 63077, 63078, 22857 and 0163T) 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis  for evaluation of her medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The advantage of tomosynthesis relates to the ability often afforded the reader in being able to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers.  For this reason the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone.Final Result:  Two reviewers determined that 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Omnitrope for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the records provided for review document that this patients height is more than two standard deviations delayed and his growth velocity is poor. In addition, the patients adult predicted height, based on the bone age and height measurement at that time is approximately, which is shorter than expected for the genetic potential and more than two standard deviations below the mean for U.S. adult males. According to  the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor binding protein (IGFBP)-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does meet most of these criteria, and he has an adult predicted height, which is short enough to warrant a trial of GH therapy based on current U.S. Food and Drug Administration (FDA) standards for treatment of idiopathic short stature. Accordingly, the requested Omnitrope subcutaneous (SQ) seven days per week is supported as medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The addition of tomosynthesis allows for better characterization of possible masses, spiculation, and architectural distortion. Moreover, there is sufficient support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, such as in this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that 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 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 56-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that in a recent report by Sheets and colleagues, the authors noted that proton beam radiation therapy resulted in a greater risk of gastrointestinal toxicity versus intensity modulated radiation therapy.  There is a lack of published clinical data demonstrating that proton beam radiation therapy could lower the risk of radiation-associated malignancies.  Per current National Comprehensive Cancer Network guidelines, proton beam radiation therapy is not recommended for routine use at this time.  In this case, the provider reported that proton beam radiation therapy is needed in order to reduce the risk of hip fracture. However, evidence to support this claim was not provided.  There are no compelling data to suggest that proton beam radiation therapy is superior to intensity modulated radiation therapy, in general, or with respect to bone sparing.  All told, the requested proton beam radiation therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested  for speech and language therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is an integral component of a comprehensive treatment plan for young patients with autism. With regard to occupational therapy (OT), the scientific evidence suggests that OT can be a useful modality for some patients with autism. To support the need for OT, numerous clinical studies have reported on the benefits that include prevention of deterioration or reversal of function, and contribution to a significant improvement in activities of daily living. In this particular case, this patients evaluation did identify an aversive feeding disorder, which likely requires the assistance of a dedicated feeding clinic oftentimes provided within occupational therapy services.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female has requested for speech therapy for treatment of her autism. Findings:  The physician reviewer found that the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.All told, it is medically necessary that this patient receive speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

The father of a 13-year-old female enrollee requested authorization and coverage of residential treatment for the treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested services are not medically necessary for the treatment of the enrollees depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that breast tomosynthesis has gained worldwide popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  In cases where the breast tissue is extremely dense or heterogeneously dense, the tomographic features of tomosynthesis allow the radiologist to sort out dense glandular tissue from architectural distortion and perhaps underlying mass.  All told, breast tomosynthesis was likely to have been of greater benefit to the patient than digital mammography without tomosynthesis.Final Result: Three reviewers determined that 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 overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. The submitted documentation supports the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Researchers noted intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function. Per researchers, viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this patients case, prior Euflexxa injections were beneficial. Therefore, the requested 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: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee has requested for the Pillar procedure for treatment of his obstructive sleep apnea. Findings:  Two physician reviewers found that there is no documentation of length of CPAP trial or why the patient was intolerant of the device. The Pillar implant has been approved by the FDA for marketing as a device to improve mild to moderate obstructive sleep apnea. Steward and colleagues noted that palatal implants for mild to moderate sleep apnea demonstrate efficacy over placebo for some outcome measures, but overall effectiveness remains limited. In a one-year follow-up study of 26 patients, Nordgard and colleagues showed reduction of apnea/hypopnea index in 80 percent of patients. The available data is not sufficient to establish that the Pillar procedure results in a superior clinical outcome despite some endorsement by national academies.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee 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 obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. The requested services are medically necessary in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. The patient has reported anxiety over being misgendered despite hormone therapy. Therefore, laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. This type of hair growth in a woman is known as hirsutism. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. The requested laser facial hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the extent possible. Laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, laser hair removal is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment patients medical condition and are reconstructive in nature. 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

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2.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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa 400-100 mg for 12 weeks 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested a positron emission tomography (PET) scan for evaluation of her medical condition.  Findings:  Two physician reviewers found that peer-reviewed scientific literature does not support utilizing PET/CT as an appropriate first line in the evaluation of localized adenopathy. PET/CT is not part of the algorithm of diagnosis, until after a diagnosis is established by tissue sampling. While PET/CT is a very sensitive test, it lacks specificity, making it an unreliable test in the screening setting. A paper by Schoeder and Gonen discussed screening exams, and the limitations of using PET/CT as an evaluation tool of localized adenopathy or lymphoma. Until a biopsy is attempted, PET/CT as a first line diagnostic tool for this incidental finding is not likely to be more efficacious for evaluation of this patients medical condition than available standard therapy. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Credentials/Qualifications:  All three 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 44-year-old female enrollee requested authorization and coverage of laparoscopic adjustable gastric band surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.