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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services.   The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. Based on the LOCUS recommendations, this patient met the criteria for the PHP level of care services. The patient was at serious risk of harm to herself (score 4) given a recent injury with a knife and ongoing endorsement of desire to die as well as self-injurious urges. The records indicate the patient continued to struggle with severe mood lability as well as urges for self-harm and panic. The patient demonstrated moderate functional impairment (score 3) as she endorsed purging at least twice monthly and had difficulty completing activities of daily living. The provider noted that the patient was frequently social withdrawn and would have dissociative episodes. The records document that the patients family was actively involved in her treatment. The patients resilience and treatment history was poor (score 4) given that she tried to hang herself in the inpatient setting and continued to cut herself in the PHP environment. She demonstrated some minor improvement during PHP treatment, but remained at high risk for decompensation. The patient was constructive in treatment (score 2). The records report that the patient was accepting of her psychiatric illness and the negative effects on her functioning. She was motivated to change, but would regress at times and engage in unsafe behaviors. She did seek out staff for support during the episodes of regression. This gives the patient a composite score of 21, which is consistent with medically monitored residential services. Based on assessment with the LOCUS criteria, patient met the criteria for continued stay in medically monitored non-residential services or PHP. Therefore, the PHP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco medication. On determining when to initiate or continue opioids for chronic pain, researchers report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The authors further note, Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has a right labral tear requiring arthroscopic surgery, which was delayed by abnormal lab results. Due to her upcoming surgery, her provider has recommended a topical compound cream, along with Motrin and naproxen for pain management, and did not recommend opioid therapy due to concerns regarding dependence and increased difficulty with postoperative pain management. The patient has been treated with a cortisone injection into the shoulder, along with physical therapy yielding small benefits. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, Norco medication is not medically necessary 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 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: Upheld

A male enrollee requested continued skilled nursing facility services for medical treatment of his medical condition.  Findings:  The physician reviewer found that the records in this patients case indicate that he has experienced favorable results following lumbar decompressive surgery.  Initially, he was allowed to leave the facility for up to four hours at a time and later the patient had recovered sufficient function to care for himself and ambulate within the facility at the independent to supervision level.  He was subsequently noted to have been ambulating from the facility to his home and back.  The records do not establish that there are medical reasons for continued skilled nursing facility services.  There are no documented skilled nursing, medical or therapy needs that could not be met on an outpatient or community-based basis.  All told, continued skilled nursing facility services were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees hepatitis C virus genotype 3a.  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. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based partially on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). In addition, delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza 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 medications 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for the removal of excessive thigh skin (thighplasty). Findings:  The physician reviewer found that removal of excessive thigh skin (thighplasty) is not medically necessary for the treatment of this enrollee.The enrollee was diagnosed with excess skin status post bariatric surgery. The enrollees provider noted the enrollee did not have recurrent infections or functional limitations from the redundant soft tissue on the buttock and thighs, or pain that was directly caused from excess skin. The enrollees provider noted the patient previously underwent laparoscopic sleeve gastrectomy, with a preoperative weight of 114 kg. The enrollees weight was 81.7 kg, with a body mass index of 26.68. Physical examination findings included excess adiposity on the superior lateral thigh and inferior gluteal area, with excess skin noted over the medial thigh. The enrollee reported skin irritation issues. A photograph of the medial thigh area shows transverse creases with no hanging pannus. The enrollee has requested authorization and coverage for the removal of excessive thigh skin (thighplasty). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this enrollee. At issue in this enrollees case is whether removal of excessive thigh skin (thighplasty) is medically necessary for the treatment of the enrollees medical condition or is reconstructive in nature. Medial thighplasty has a high rate of minor wound healing problems. Full-length vertical thighplasty is associated with prolonged edema. Concomitant liposuction may also increase complications. This patient underwent laparoscopic sleeve gastrectomy with significant weight loss resulting in loose skin in her thigh area. No hanging panniculus of thigh skin is visible in the photographs received for review. The enrollee endorsed skin irritation, but there is no report of appropriate medical treatment of a rash or of failure of appropriate medical treatment of a rash. The enrollee does not have a functional problem with a rash that has been demonstrated to be resistant to appropriate medical treatment. The medical evidence does not support the requested service in this clinical setting. Therefore, removal of excessive thigh skin (thighplasty) is not medically necessary for the treatment of this enrollee. Excess thigh skin and fat is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. Excess skin is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors, or disease. The requested removal of excessive thigh skin (thighplasty) is not likely to improve function or create a normal appearance to the extent possible. There is no indication that the enrollee has difficulty ambulating or diminished function due to her excess skin. Therefore, the requested removal of excessive thigh skin (thighplasty) is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

The patient was diagnosed with sleep apnea in October 2002. A CPAP machine and supplies were requested by her primary care physician (PCP). At that time, an IQ CPAP mask and headgear were requested. A nasal application device and headgear were authorized. A durable medical equipment provider supplied a nasal IQ CPAP mask as a courtesy. The patient has been tolerating CPAP well since that time, with good compliance documented in her medical visits with her PCP.The patient has been successfully using nasal CPAP for two years and does not tolerate any type of forehead pad due to forehead pressure and pain it causes. The patient attributes this to her allergy and sinus problems. The patient has now requested a nasal IQ CPAP mask and Holey Cap Headgear. The patients request has been denied by the Health Plan on the basis that the submitted documentation does not support the need for the special features of the requested equipment. A standard CPAP has been recommended.The patient has documented sleep apnea. Individual patient fit and tolerance are used to determine the best mask type to use in medically managing a patients sleep apnea. This patient clearly tolerates nasal CPAP over a full-face mask. She is not tolerant of any head strap against her forehead due to complaints of pressure and pain. She has been very compliant with CPAP use and has been tolerating it well for almost two years using a nasal IQ CPAP mask.Furthermore, special mask types may be necessary for patients who are unable to tolerate a standard nasal/face mask due to facial discomfort, sinus pain, or claustrophobia from masks. If the patient does not tolerate the type of nasal CPAP mask that is routinely supplied, then special consideration should be provided to this patient to allow her to continue to use the mask type that she has been able to tolerate and use successfully for almost two years.Based upon the information set forth above, I have determined that the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female who experienced significant breast pain following placement of mammary implants.  The original breast implants and the breast capsules were removed in May 2005 and overfilled saline implants were placed. The patient has requested reimbursement for cost of the procedure.  The Health Plan denied her request based upon a determination that the capsulectomies were not medically necessary.My review included the office notes of the treating plastic surgeon and photocopies of photos apparently taken on the day of the procedure. A letter from the provider to the Health Plan dated one month after the procedure was also reviewed. It is not possible to determine the location (above or deep to the pectoralis muscle) of the contracting implants from the providers notes or the photographs. Similarly, it is not possible to determine the degree of firmness of the capsules from this limited documentation.  Based on the lack of documented clinical findings, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested for a nerve block for treatment of her post-operative pain. Findings:  The physician reviewer found that regional anesthesia (nerve block) is standard of care for shoulder surgery, and it has been for the past several years. It provides excellent post-operative analgesia, minimizes the need for narcotics post-operatively and decreases the need for excessive anesthesia during the operation.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee requested sensory integration occupational therapy services for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that sensory interventions can be effective for many children with ASD, especially with self-regulation and teaching self-control. Sensory integration therapy often makes the OT more effective in teaching self-regulation while teaching ADLs. Occupational therapists who are knowledgeable in sensory interventions can provide parents with tools to help them relate to autistic children and to teach effective tools to help them in difficult situations. Moreover, sensory strategies can be useful tools for children with ASD to address anxieties, self-regulation delays or hyperactivity. In this case, the use of sensory intervention techniques provided has improved the patients ADLs and compliance with requests. The documentation submitted for review indicates that the patient responds and has benefited from sensory integration occupational therapy services. Given the support for sensory based therapies in this clinical setting, the medical necessity for the requested therapy has been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested extracorporeal shock wave therapy (ESWT) for the treatment of her foot pain. Findings:  Two physician reviewers found that ESWT is an FDA approved treatment for chronic proximal plantar fasciitis.  Most, if not all, studies demonstrate efficacy as compared to placebo.  Review of the literature reveals an efficacy rate of between 50-75%.  However, standard minimally invasive endoscopic plantar fasciotomy demonstrates an effective rate of 90%.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing (molecular profiling) for evaluation of his lung cancer with brain metastasis. Two physician reviewers found that molecular profiling is an assay of an individual patients cancer cells to detect specific genomic or molecular abnormalities that might serve as a target for a potential treatment. There are multiple non-randomized clinical trials exploring the value of molecular profiling. However, there is a lack of data from these trials demonstrating improved health outcomes based on the findings in these assays. Currently, there is a paucity of scientific data suggesting that the genetic testing (molecular profiling) was likely to have been more beneficial than standard available testing. Final Result: Two 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Two reviewers are board certified in oncology and hematology 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 52-year-old female enrollee has requested the medication Xyrem for the treatment of her fibromyalgia. Findings:  The physician reviewer found that the patient does not have a diagnosis of narcolepsy.  She is on central nervous system depressants. Xyrem is not the standard of care for treatment of this patients conditions.  As such, the continued use of Xyrem is not clinically indicated and should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested authorization and coverage for artificial intervertebral disc arthroplasty (total disc replacement therapy utilizing the Pro-Disc Cervical Artificial Disc).  Findings:  Three physician reviewers found that the patient has progressively worsening neck pain. The patients MRI evidenced a 4.5mm central and left central paracentral disc herniation at C5-6 and a 3mm left paracentral disc protrusion at C6-7. A neurological examination evidenced the patients strength to be 5-/5 in the left deltoid, biceps, triceps and wrist flexors and extensors, with decreased sensation in the left C6 dermatome. The Health Plan has denied the requested artificial intervertebral disc arthroplasty (artificial disc replacement) with ProDisc C as investigational.  Despite the fact that artificial discs have been implanted for almost 15 years, there is currently insufficient data in the available peer reviewed medical literature to adequately assess the performance of total disc replacement. Anterior cervical discectomy and fusion (ACDF) is considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion may result in progressive degeneration of the adjacent segments. Therefore, disc arthroplasty has been introduced. While artificial disc replacement seems to be promising in terms of preserving segmental motion, this is very difficult to judge and has not yet been proven. There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Further, total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Therefore, total disc replacements should be considered unproven procedures. This is particularly true for this patient, as she has significant disc degeneration at C5-6.  Total disc replacement is not a superior treatment alternative to a one-level fusion for an individual with this patients condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested acute inpatient psychiatric services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has essentially given up and wishes to be left alone. Based on the documentation submitted, this patient has the danger signs of someone who would end his own life if allowed to do so. He is hopeless, apathetic, severely depressed and does not wish to continue to live in this state. Thus, acute inpatient psychiatric services were medically necessary for medical treatment of his behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the residential treatment center services provided. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. Studies recommends residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills, and drug-free social supports to maintain abstinence in an outpatient setting. This patient was using large amounts of nitrous oxide every day and was unable to stop using despite treatment in a lower level of care. The patient was unable to function at work, school, or socially despite lower levels of care. A standard rehabilitation program of a 30-day residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for this patients illness. Therefore, the residential treatment center services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.