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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine for evaluation of his of thoracic spine pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The only reason to obtain an imaging study is if it will alter the course or type of therapy.  In this patients case, the records do not specifically address symptoms in the neck or cervical spine.  Based on the clinical notes, there is not a direct indication to warrant a cervical spine MRI.  The American College of Radiology (ACR) has attempted to provide evidence-based guidelines to help guide choices for diagnostic procedures.  In this clinical setting, the American College of Radiology (ACR) has recommended plain x-rays as a first line study, and specifically states that MRI of the cervical spine is generally not appropriate.  Were the patient to have specific neurological signs or symptoms, then an MRI may be appropriate.  Additionally, findings on MRI do not necessarily correlate with symptoms.  It is well known that a patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on MRI but may be experiencing significant symptoms. The current medical evidence does not support the requested services in this patients case.  All told, the requested MRI of the cervical spine is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

The parent of a two-year-old male enrollee has requested occupational therapy and speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that upon reviewing this patients medical records, it becomes clear that the requested speech therapy and occupational therapy are medically necessary for treatment of his delays secondary to autism. This conclusion is based on an overall evaluation of the relevant medical literature. Lane and Schaaf discussed the notion of plasticity in the developing brain in terms of rehabilitation outcomes in young patients with developmental deficits. The authors noted that although the patients present with underlying neurologic disease, such as the pathogenetic process that gave rise to this patients speech and physical delays, therapy can be utilized to improve overall neurologic health. Thus specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech therapy and occupational therapy are medically indicated for this patient to reduce the physical and mental effects of his underlying neurologic condition and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested Lyrica for treatment of her burning, aching, and throbbing sensations in her feet.  Findings:  The physician reviewer found that the available medical records describe a condition of burning pain, which could be related to neuropathic pain, but is otherwise not specified in terms of etiology. The records do not demonstrate that the patient has a diagnosis of fibromyalgia, a diagnosis of post-herpetic neuralgia, neuropathic pain associated with diabetic peripheral neuropathy, epilepsy, or seizures. In addition, the medical records do not document that the patient has tried at least two other agents and failed such treatment in response to her pain condition. Although the patient was being treated with Cymbalta and did not respond to positively to this medication, the available medical information does not support a medical necessity for Lyrica as a part of this patients treatment plan. Consistent with these findings, the use of Lyrica is not supported as medically necessary in treating this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested for a CT heart scan for coronary artery calcium for evaluation of her coronary disease risk factors. Findings:  Two physician reviewers found that current National Cholesterol Education Program Adult Treatment Panel III guidelines do not recommend routine screening with coronary calcium scoring in asymptomatic patients. There is no data to indicate that changing a statin medication dose based upon the testing at issue favorably affects outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested prostate cancer antigen 3 testing (PCA3) gene expression test for treatment of his elevated prostate-specific antigen (PSA).  Findings:  Three physician reviewers found that the PCA3 gene expression test performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. PCA3 testing is approved for use in screening for prostate cancer in patients who have had an elevated PSA and previously negative biopsy. The documentation submitted for review show no indications for the PCA3 test as there is no evidence of history of a prior prostate biopsy or an elevated PSA. All told, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested an X-STOP spacer device implantation for the treatment of her low back and leg pain. Findings:  Two physician reviewers found that there are several relative contraindications to the use of the X-STOP spacer device. The anatomical studies document grade 1 spondylolisthesis, which is likely to be aggravated by the device, which increases the intraspinous distances and diminishes the stability of the spine in a posterior to anterior direction. Furthermore, the presence of multi-level neural foraminal and central spinal stenosis is a relative contraindication with insufficient clinical documentation of a specific single level appropriate for insertion of the X-STOP. In addition to these relative contraindications, the use of the X-STOP spacer device is not supported by Level I and Level II studies as an alternative to standard care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:A 23-year-old male enrollee has requested authorization and coverage for gynecomastia surgery. Findings: The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested surgery. The patients bilateral masses and correctable causes have not been sufficiently evaluated. A report of relevant laboratory studies and endocrine work-up is not documented. In addition, the patients pain and discomfort does not show that it is due to distention and tightness from hypertrophied breast. Moreover, the photographs show gynecomastia grade of I or II, which is relatively mild to moderate. The records also do not mention a concern for possible malignancy based on examination detail and mammography results. Therefore, based on the documentation provided for review, the request for gynecomastia surgery has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for wilderness therapy. The enrollee has a history of mental health disorder and substance abuse.  He entered into the intermediate outdoor behavioral health program. Findings: according to group session note summaries, the enrollee participated in group therapy sessions, which included outdoor activities, mindfulness exercises, vulnerabilities, daily reflections and readings from 12-step program handbooks. In current literature, wilderness therapy is an identified treatment modality for a wide range of populations and client problems.  The medical literature indicates therapeutic approaches, including nature as a therapeutic tool, need to embrace evidence-based practice so that clinicians may continue to utilize treatment and interventions based on the best available science.  Wilderness therapy is described as an eclectic framework for working with at-risk youth within the commonality of the natural setting, reliance on group interactions, and the perception of risk in activities.  However, the lack of standardization, lack of clear evidence-based practices, inconsistencies in treatment intervention, and wide range of treated populations causes wilderness therapy to appear to be an ambiguous treatment modality. Results are not clearly delineated. Youth with clinical diagnoses or substance use problems can use this technique to address a range of adolescent problems, including rebellion, self-doubt, and substance use.  The typical stay for this type of treatment has some variance as the treatment is to be customized based on the enrollees needs; however, average stay is eight to ten weeks. The record notes the enrollees history of substance abuse and mental health disorder, unspecified diagnoses, and the review of notes regarding the enrollees treatment interventions at this level of care. He primarily engaged in group therapy sessions. There is no evidence in the record that the enrollee obtained services above and beyond those available to him at a lower level of care.  Notes indicate the enrollee only participated in group therapies; most of which were focused on his emotional status, mindfulness, coping skills, and the 12-step program regimen. The record did not indicate the enrollee had a crisis or exacerbation of symptomology warranting this level of care an above-average length of stay beyond standard treatment guidelines for this type of treatment.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in psychology 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 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 33 hours per week of direct applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training for treatment of the enrollees autism. Findings: The physician reviewer found that one article studied 726 autistic children, ages 1.5 to 12 years, who were found to make increased progress towards learning objectives with increased intensity of ABA treatment. The Health Plan has authorized 16 hours per week of direct ABA and six hours per month of oversight. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Per the most recent progress report, the patient continues to demonstrate significant delays in vocal stereotypy, outburst behaviors and non-compliant behaviors. Failure to master these skills puts the patient at an increased risk for injury. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 reimbursement for the computed tomography (CT) scan of the heart without dye with calcium test for evaluation of the enrollees chest pain, abnormal electrocardiogram, and mixed hyperlipidemia. Findings:  Two physician reviewer found that Use of the calcium score has been supported by the American College of Cardiology (ACC) as a class IIa or IIb category, which states that this testing may be beneficial in asymptomatic individuals with intermediate coronary risk. Other studies such as exercise testing or coronary angiography are recommended in symptomatic individuals. Since this individual was having chest pain and abnormal EKG with right bundle branch block pattern and past history of syncope, the contrast CT coronary angiogram was indicated, but calcium scoring is not recommended in symptomatic patients. Accordingly, the CT scan of the heart without dye (CPT code 75574) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy while the calcium test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that a portion of the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular medicine and are 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

The patients parent has requested reimbursement and prospective authorization and coverage for services provided at a specific facility. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Applying the CALOCUS criteria, this patient has significant potential for risk of harm (score 4) given his history of violence toward his parents, therapist and coach as well as possession of a gun. He has demonstrated moderate functional impairment (score 3) and continues to refuse to take medications to improve his symptoms. The patient has significant comorbidities (score 3) that interfere with his ability to make demonstrable progress in treatment including abuse of cannabis. The patient is likely bipolar due to his poor impulse control, irritable mood, insomnia, agitation, and violent behavior. The patients recovery environment is moderately stressful (score 3) given the patients history of violence toward his family members and possession of a gun without his parents knowledge. The patient has a role expectation that exceeds the patients capacity given his age and developmental level. The patients recovery environment is supportive (score 2) as his father is a physician who is invested in the patients welfare. The patient has demonstrated poor response to prior treatment and recovery management (score 4) without remission or control of symptoms. The physician reviewer found that provider reports the patient is making slow progress and requires long-term placement to continue to make progress. The patient has been adversarial in treatment (score 4). The records document that the patient has been actively hostile with his providers. His parents have been willing to accept and participate in the patients treatment plan (score 2) and have engaged in therapy via videoconferencing. This gives the patient a composite score of 25, which is consistent with medically monitored residence based services, such as residential treatment center (RTC). Based on the patients risk of harm, he qualifies for medically monitored residence based services, both on CALOCUS mandatory and composite scoring criteria.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee requested authorization and coverage of surface replacement arthroplasty of the left hip. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees osteoarthritis.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

The parent of a female enrollee requested the EZ Ride Stroller for medical treatment of the enrollees Pitt-Hopkins syndrome and cerebral palsy.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with Pitt-Hopkins syndrome, cerebral palsy and epilepsy. The requested stroller is clinically indicated as the patient is an unsafe ambulator who is only able to walk for up to 20 minutes, is a fall risk, has poor safety awareness, and has seizures. Based on the medical literature cited above and the documentation submitted for review, the request for the EZ Rider Stroller is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old male has requested authorization and coverage for a Bantam stander for the treatment of the enrollee who has been diagnosed with microcephaly and global developmental delay.  Findings:  2/3 of the physician reviewers found that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The device will enable the patient to assume a variety of functional positions and facilitate weight-bearing on his long bones.  This is likely to decrease the risk of osteoporosis as well as  decrease the risk of developing contractures of the hip, knees and ankles. There will also be a decreased risk of pressure sores. Appropriate positioning will aid the maintenance of normal gastrointestinal function. Colleagues describe the beneficial effects of dynamic standing to increase cortical bone mineral density. Additionally, Hough and colleagues showed a large and significant effect on the lumbar spine when increasing static standing time. For these reasons, a Bantam stander is likely to be more effective for treatment of this patients medical condition. Final Result: 2/3 of 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 reviewer number one is board certified in pediatrics and 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.Physician reviewer number two is board certified in pediatrics and 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.Physician reviewer number three is board certified in pediatrics and 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: Upheld

A 40-year-old female enrollee has requested cervicoplasty (removal of redundant skin and subcutaneous tissue from the neck with a lift) for treatment of her excess skin. Findings:  The physician reviewer found that with regard to whether the proposed surgery is reconstructive in nature, the documentation does not support the presence of an abnormal structure of the body in this patient. The skin is abnormal on a microscopic level, but the impact is only minimal at the macroscopic level, as the only symptom is some visibly lax skin. The excess tissue is not so great so as to be considered abnormal at a macroscopic visual level. In fact, the photographs do not show much more changes than are expected from the normal aging process. Thus, the California statute regarding reconstructive surgery does not apply. The proposed surgery is in fact a variant of a regular facelift. Concerning general concepts of medical necessity, the submitted documentation does not establish the presence of a functional impairment in this patient. The skin lesions and manifestations of pseudoxanthoma elasticum are asymptomatic. In the absence of evidence of infection, rashes, loss of skin integrity or so much excess skin that it restricts mobility, the removal of this skin would be cosmetic and not medically necessary. Therefore, the requested surgery cannot be seen as being performed to improve function.