Persius/imr-appeals huggingface dataset:
A 57-year-old male has requested approval for an increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) for treatment of his chronic pain and depression.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantities in this patients case.  He has a known chronic pain condition and is on treatment with multiple medications, including narcotics.  Sources of chronic pain include neuropathic pain, visceral pain, and musculoskeletal pain.  Per the current medical evidence, treatment approaches can include combinations of medical therapy, behavioral intervention, interventional therapies, and rehabilitative interventions.  The current medical research indicates that treatment with narcotic analgesics for a period of greater than two weeks does not result in more favorable pain control than the use of non-steroidal anti-inflammatories or acetaminophen. Many studies have documented the high degree of comorbidity between depression and chronic pain, and there is evidence that the incidence of depression among patients with chronic pain is higher than for other chronic illnesses.  Per the medical documentation, the patient has a signed Controlled Substance Contract with his provider.  The records indicate that the patient tested positive for codeine and morphine, and these medications were not prescribed by the treating provider.  This constitutes a breach in his signed Controlled Substance Contract.  The current medical evidence does not support the requested increase in medications in this clinical setting.  All told, the requested increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) is not medically indicated for the treatment of this patient.
A 67-year-old female has requested coverage for transportation for treatment of congestive heart failure, chronic obstructive pulmonary disease, obesity, and hypertensive heart disease.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this clinical setting.  The medical records do not demonstrate the medical necessity of non-emergency transportation in this patients case.  There is no documentation indicating that she requires transportation other than by means of public or private conveyance.  She has no specific impairments which require transportation to and from medical visits.  The clinical notes indicate that the patient is able to ambulate without documented deficits, and she has no medical condition which requires structured transportation.  All told, the requested transportation is not medically indicated in this case.
The representative of a 45-year-old male has requested admission to an acute rehabilitation facility that specializes in brain injuries for treatment of his medical condition status post brain aneurysm and intracerebral hemorrhage.   Findings:  The physician reviewer found that based on review of the available records, the patient has sustained a severe brain injury. His hospitalization with severe pneumonia in underscores the severity of his illness. The medical literature, including Eskildsen and colleagues review, discuss the indications for long-term acute care. Specifically, the authors noted that a patient needs to have an unstable condition with a need for multiple specialists providing frequent care. This patients medical condition currently is one of severe brain injury and chronic ventilator dependence. He is at high risk for recurrent pneumonia but does not have multiple organ dysfunction. In addition, he continues to have severe brain injury and ventilator dependence more than three months post-stroke. He is unable to make gains consistent with intense rehabilitation. He will need a protracted course with rehabilitation with small gains expected over a long period of time. The anticipated benefit from acute rehabilitation follows from progressive recovery from brain injury. The degree of this patients brain injury prohibits him from progressing with intensive therapy at this time. All told, the requested services are not supported as medically necessary in treating this patients medical condition.
The parent of a 5-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 35 hours per week for treatment of the enrollees global developmental delay and autism spectrum disorder.  Findings:  The physician reviewer found that Based on review of the available records, both the patients pediatric neurologist and her clinical psychologist diagnosed her as autistic and independently recommended 20 to 35 hours of ABA therapy. The patients intellectual disability is a frequent co-morbid diagnosis in autistic children. However, this condition does not preclude the patient from benefitting extensively from ABA therapy. ABA therapy is well-documented as the only consistently successful intervention for autistic children. The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a documented 40-year track record of substantially improving motor, verbal, and socially interactive skills in autistic children. Myers and Johnson indicate that the effectiveness of ABA-based intervention in autism spectrum disorder has been well-documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Further, the authors report that, children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. This patient has been diagnosed as autistic, for which ABA therapy is the well-documented therapy of choice. There is consensus among clinical psychologists that ABA therapy should be intensively initiated as soon as a diagnosis of autism is established. With regard to the appropriate frequency of ABA therapy, at the requested 35 hours per week of ABA services, there would be inadequate time to develop group socialization or trials of mainstreaming the patient during school hours. A frequency of 20 hours of ABA therapy per week is more appropriate in this setting. All told, it is medically necessary that ABA therapy be continued for this patient. However, the recommendation is for 20 hours of ABA therapy per week.
A 43-year-old female has requested aquatic therapy for treatment of her Dercums disease and lymphedema.  Findings:  The physician reviewer found that based on review of the available records, the patient has a severe and rare debilitating condition that requires a multifaceted approach for effective treatment. The medical literature indicates that clinical benefits from an aquatics program include improvement in strength, mobility, and overall well-being. Consistent with this support, this patient would benefit from a therapeutic aquatic exercise program. Given the significant pain and limited mobility associated with her condition, aquatic therapy is medically necessary.
A 63-year-old male enrollee has requested for gastric Lap-band surgery for treatment of her obesity. Findings:  The physician reviewer found that the medical records do not document completion of a multidisciplinary evaluation, including a dietary evaluation, behavioral evaluation, and medical evaluation.  In the absence of this documentation, the medical necessity of the requested procedure cannot be established.  Additionally, failed weight loss efforts should be documented prior to the requested surgery.  All told, the requested gastric Lap-band surgery is not medically indicated for the treatment of this patient at this time.
A 62-year-old female enrollee has requested for chiropractic services for treatment of her left hip and low back pain. Findings:  The physician reviewer found that there is no clinically significant benefit with respect to analgesic, health or functional outcomes is expected with chiropractic therapy at this time based on the available clinical data.  There is no proven benefit of chiropractic treatment in the setting of chronic low back pain, chronic hip pain, or other musculoskeletal conditions.  In the review by Ernst and colleagues, the authors concluded that rigorous clinical trials have not demonstrated that chiropractic care is an effective intervention for pain control.  In 2008, Bronfort and colleagues did not note significant, sustained benefit to spinal manipulation and mobilization over other conservative management.  Although the patient remains symptomatic, the requested chiropractic therapy is not reasonably expected to provide significant clinical benefit beyond an ongoing physical therapy program or an independent exercise program.  All told, the requested chiropractic services are not medically indicated for the treatment of this patient.
A 48-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that based on review of the records, medical necessity has not been established for the requested bariatric surgery procedure. As noted in the medical literature by Smith and colleagues, Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. This patients records do not document any of these conditions.  Accordingly, the requested surgery is not medically necessary for treatment of the patients medical condition.
A 42-year-old female enrollee has requested authorization and coverage for removal of breast implants for treatment of a ruptured breast implant. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Removal of breast implants would be considered medically necessary for the treatment of active infection, impending or actual implant extrusion, painful symptomatic grade IV capsular contracture, or leakage of silicone gel.  The existence of any of these conditions is not documented in the reviewed materials.  It is unlikely that a deflated saline implant in the absence of grade IV capsular contracture or infection would cause any functional deficit.  Based on the information provided, removal of breast implants is not medically necessary for the treatment of this patient. Given the absence of high-grade capsular contracture, capsulectomy is also not medically necessary.
A 60-year-old female has requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that the patient's provider reported that the patient has been resistant to treatment with multiple trials of psychopharmacologic agents, including Emsam patch, Elavil, Cymbalta, Lexapro, Prozac, Effexor, Remeron, Zoloft, Abilify, nortriptyline, Luvox, Desyrel, Celexa, imipramine, Paxil, Wellbutrin, and Pristiq.  The patient reported thoughts of suicide, anhedonia, cognitive impairment, interpersonal withdrawal, difficulty sleeping, suicidal ideation, irritability, fatigue, and weight changes.  The provider noted that the patient had electroconvulsive therapy in the past, with no response.  In this patients case, the requested services are likely to be of greater benefit than other available treatment alternatives.  The American Psychiatric Association has noted that transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not respond to medication therapy.  This patient has already undergone 25 sessions of electroconvulsive therapy, with no response.  Her prior medications have included combinations of antidepressants, mood stabilizers, and anti-anxiety medications.  Psychotherapy and cognitive therapy have also been provided.  The patient continues to be symptomatic.  In this clinical setting, transcranial magnetic stimulation is likely to be more beneficial than other treatment modalities.  All told, the requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) is likely to be superior over other treatment options in this patients case.
The parent of a four-year-old male has requested occupational therapy for treatment of his eating disorder.  Findings:  The physician reviewer found that feeding difficulties are common in early life with 25% of children reported to have some form of feeding disorder. Consequences of feeding disorders can be severe, including growth failure and susceptibility to chronic illness. Feeding disorders occur in children who are healthy, who have gastrointestinal disorders, and in those with special needs. Caretto and colleagues evaluated the role of occupational therapists in parent education of infant feeding in the neonatal intensive care unit. The occupational therapists were most frequently identified as responsible for teaching about positioning, infant development, and infant states and cues and were highly involved in educating parents about feeding. Although this study involved neonates, this does prove that occupational therapists have a role in the treatment of feeding problems and are the main providers in the treatment of feeding disorders. Most feeding disorders have underlying organic causes. However, overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psychosocial and organic factors. Disordered feeding in a child is seldom limited to the child alone and is oftentimes a family problem. Assessment and treatment are best conducted by an interdisciplinary team of professionals. At minimum, the team should include a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. Intervention should be comprehensive and include treatment of the medical condition, behavioral modification to alter the patients inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oromotor, and behavioral therapy. For these reasons, the requested occupational therapy is medically necessary to prevent malnourishment, failure to thrive, and to reduce morbidity in the treatment of this patients medical condition.
The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
A 28-year-old male enrollee has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient sought emergency services for complaints of left eye redness, swelling and pain. He had a history of a chalazion for several months. Approximately a week prior to his visit to the emergency room, he developed increased swelling to the chalazion in his left eye. He applied warm compresses which he continued for one week with little improvement in his symptoms.  The patient left for a vacation and while away, the pain and swelling in his eyelid increased and there was a small amount of discharge. The patient sought medical attention at an emergency room. He had no fever and there was no loss of vision. The swelling was contained to his eyelid. The infection was drained and the patient was placed on antibiotic ophthalmic ointment.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention.  California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Chalazions are not acute medical emergencies. They are typically managed with warm compresses and antibiotic ointment with referral to an ophthalmologist when that fails.  In this case, the patient reports he experienced a significant worsening of pain and swelling and that his vision was blurry. The emergency physician record indicates that the patients pain in the emergency room was 2-3 out of 10 and his visual acuity was 20/20. The patient did not require narcotic analgesia. He received Motrin for pain. All told, the objective medical record documentation does not support the contention that the patient experienced a significant worsening of pain, swelling and vision problems at the time he sought emergency services. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health and thus would not have sought immediate medical attention for the patients complaints.
The parent of a seven-year-old male has requested a mitochondrial muscle biopsy for evaluation of his stated condition of a possible metabolic/mitochondrial disorder.  Findings:  The physician reviewer found that this patient has ASD but does not exhibit other symptoms to suggest a mitochondrial disorder. Signs of mitochondrial disease include elevations of lactic acid, which the patient does demonstrate.  However, blood lactate and pyruvate measurements are known to be prone to erroneous increases due to such issues as prolonged tourniquet application, (see Bonini, et al. and Haas). Other biochemical markers are often present including elevation of plasma alanine in the amino acids, elevations of urine organic acids and especially dicarboxylic acids due to omega oxidation of fat in the cytoplasm when mitochondria are not functioning normally.  Elevations of acylcarnitine derivatives are usually seen, as well.  Ammonia can also be elevated with mitochondrial disease (Haas). The patient exhibited none of these biochemical markers. Finally, patients with mitochondrial diseases usually have progressive deterioration in their neurological functioning (Haas) which is also not evident in the documentation provided regarding this patient. Therefore, without additional signs or symptoms as outlined above, a muscle biopsy for the purpose of a mitochondrial disease work-up is not medically necessary for the patient.
A 45-year-old male enrollee has requested Interferon Alpha injections for treatment of his Peyronies Disease. Findings:  The physician reviewer found that the literature evidences that the etiology of Peyronies Disease is not clearly understood, however the effect of the disease is a plaque that affects the elasticity of the corporal body. This results in non-uniform distension of the corporeal bodies which leads to a curvature of the erection. The surgical treatment of the plaque is still considered to be the standard method of treatment when a patients disease is determined to be stable and mature (Gordon). As with other methods of treatment for Peyronies Disease, Interferon therapy requires further investigation to define its efficacy, proper dosing regimens and side-effect profiles (Larsen & Levine). In sum, the requested medication is not considered medically necessary in this setting, as this treatment modality is still being evaluated and is not considered to be an accepted option for treatment of the patients medical condition.
A 61-year-old female enrollee has requested for emergency services indicating emergency care. Findings:  The physician reviewer found that complaints including cough, chills, body aches, vomiting and abdominal pain.The patient was diagnosed with an upper respiratory infection. The patients condition did not improve and she sought medical attention at a facility.
A 20-year-old male enrollee has requested a prosthetic running limb for treatment of his status post an above-the-knee amputation.  Findings:  The physician reviewer found that this patient has goals of competing in the 2012 Paralympics, and he has requested a prosthetic running limb. Prostheses for running are specially adapted for this task.  However, these adaptations are not necessary for an individual to accomplish basic mobility-related activities of daily living. The patient currently uses a prosthesis that allows him to accomplish his mobility-related activities of daily living, including community mobility. The requested equipment adds to the patients options for exercise and recreation, but it is not medically necessary.  The submitted medical records do not demonstrate the medical necessity of the requested equipment.  All told, the requested prosthetic running limb is not medically indicated.
The parent of a 7-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient with autism will continue to benefit from intensive ABA therapy and has shown impressive gains in all domains since the start of treatment. The American Academy of Pediatrics (AAP) recommends a minimum of 25 hours per week of ABA therapy per week for children with autism. As this is the standard of care for patients with autism, 25 hours per week of ABA therapy is medically necessary for the management of this patients behavioral issues associated with autism.
The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech/language delay.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  The current medical evidence indicates that early intervention can improve speech and language skills.  Recent studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, given the degree of his speech and language delay, the requested speech therapy is standard of care. There is sufficient medical evidence supporting the requested services in this clinical scenario.  All told, the requested speech therapy services are medically indicated for the treatment of this patient.