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

The parent of a five-year-old male enrollee has requested coverage for occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that evaluation of fine motor skills showed grasping was good and pronation/supination was within normal range of motion. With regard to gross motor skills, it was noted that the patient is walking, is able to hop on one/two feet and able to climb, throw and catch/kick a ball. Oral motor skills were noted as normal, with the patient described as eating using standard utensils, drinking from a cup and feeding himself.  Based on the evidence, the patients deficits are not functionally based and therefore the patient does not meet clinical indications for occupational therapy. While the patient does have sensory issues, these issues are best addressed in conjunction with other treatment modalities. Accordingly, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 34-year-old female enrollee has requested an MRI for an evaluation of her pelvic pain. Findings:  Three physician reviewers found that the patient had severe pelvic and hip pain that persisted after delivery. Physical therapy was attempted and was unsuccessful. MRI provided the soft tissue and bone analysis necessary to make the diagnosis of tendinitis and partial thickness tears. MRI was the preferred method to evaluate the soft tissues in this clinical situation. The technique was clinically indicated for evaluation of the pelvis at the site of tendinous insertions. The diagnosis was made in this particular case using MRI
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 16-year-old male enrollee has requested vision therapy for treatment of the enrollees ocular motor dysfunction. Findings:  Two physician reviewers found that the requested therapy is not likely to be more effective for this patient than other available options. Vision therapy for the treatment of the patients diagnoses is not medically indicated. The patient has diagnoses of ocular motor dysfunction, binocular vision dysfunction and accommodative dysfunction. The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with ocular motility disorders, accommodative dysfunction, learning disabilities, visual field defects and visual acuity (Rawstron et al). Given the lack of evidence for and standardization of office-based treatments, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested  for Lupron Depot pediatric injections for treatment of the enrollees precocious puberty. Findings:  The physician reviewer found that the patient does not meet the standard accepted criteria for precious pubertal development.  In this clinical setting, continued administration of Lupron Depot pediatric injections is likely to have a deleterious effect on bone mineral accretion and may increase the patients risk of osteoporosis.  The current medical evidence does not support the requested therapy in this case.  All told, the requested Lupron Depot pediatric injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee with a diagnosis of  history of bilateral hand osteoarthritis. X-rays of the bilateral hands, demonstrates mild osteoarthritis of the right first carpometacarpal joint with osteophytes, mild osteoarthritis of the bilateral thumb interphalangeal joints with small osteophytes, mild osteoarthritis of the left third proximal interphalangeal (PIP) joint with small osteophytes. She cannot tolerate non-steroidal anti-inflammatory drugs and Tylenol has had lack of efficacy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees osteoarthritis.This is a case of a patient with hand osteoarthritis and trigger finger. A recent systemic review found that for non-pharmacological treatment of chronic pain, `For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term.. A recent review did not demonstrate efficacy of acupuncture for peripheral joint osteoarthritis. Acupuncture as an adjuvant to an exercise based physiotherapy program did not result in any greater improvements than the exercise program alone. Researchers noted Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.` The guidelines do not recommend acupuncture for the treatment of osteoarthritis. As such, the request for acupuncture services is not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in allergy, rheumatology, and immunology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an enrollee has requested authorization and coverage for removal of a benign mole on the right cheek.Although common congenital and acquired melanocytic nevi are largely benign, they are one of the most common indications for cosmetic surgery encountered by dermatologists. Melanoma is uncommon in the pediatric age range. Only 1-2% of skin tumors excised in children turn out to be malignant when examined histologically. Some benign skin tumors of childhood tend to regress spontaneously within a few years but may cause complications at particular locations and when multiple. In this case, records indicate that the patients congenital nevus was noticed since kindergarten, that it has been growing over time, and that it is larger in size. Accordingly, the warning signs of malignancy are not present in this case. Under these circumstances, the requested removal of a benign mole on the right cheek is not medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patients congenital nevus of the face does not constitute an abnormal structure of the body. It is a common and largely benign indication for cosmetic treatment. Therefore, the requested removal of a benign mole on the right cheek is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. The reviewer also determined that the patients benign mole on the right cheek did not constitute an abnormal structure of the body and that the requested services were thus not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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

The parent of a six-year-old female enrollee has requested speech therapy services for the treatment of the enrollees communication delay. Findings:  The physician reviewer found that this patient exhibited significant language delays on her initial evaluation. Speech therapy was initiated. She had made progress but still had a cognitive verbal delay of 12 months, and a language delay of about 12 months as well. Thus, continued speech language therapy was therefore clearly indicated, with the likely need for at least an additional 12-18 months of treatment based upon her rate of progression up until that point. Re-evaluation showed a 1-2 year delay depending on the assessment tool used, in both receptive and expressive language skills. Although different tests were employed at the two evaluations, and therefore direct comparison of scores is not possible, it is clear that continued speech therapy was warranted. However, the therapy provided in the second round utilized the Tomatis method. While traditional speech therapy services have established efficacy in this setting, the Tomatis therapy has not been proven to be efficacious. A recent study of the Tomatis method in 2008 (Corbett, et al.) showed no improvement in the condition of the treatment group, compared to a positive result in the placebo group. Given the lack of evidence demonstrating the benefit of Tomatis therapy it was not indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for labiaplasty surgery. Hayes and Temple-Smith stated that, The most popular of the female genital cosmetic surgeries is labiaplasty, which involves cutting back the labia minora so that they sit flush with, or are entirely hidden by, the labia majora. Ozer and colleagues commented that, Most women applying for labiaplasty have labia minora that would be considered a natural size by a medical professional, emphasizing the importance of having a validated definition of the natural variation in labia size. The Franco classification divides labia minora width into four groups: less than 2 cm; 2-4 cm; 4-6 cm; and greater than 6 cm. In a study of 200 premenopausal women not seeking labiaplasty, Widschwendter and colleagues reported that, The median width of the labia minora was 19.0 mm, and the median length was 35.5 mm. The objective size of the labia was significantly associated with womens subjective perception of the labial size, but not with self-reported complaints. This patient presents with complaints of pain, discomfort, and irritation from the labia minora since puberty. Photographs show that the patients labia minora is within the wide documented range of normal without evidence of irritation or deformity. Based on the medical information received for review, the requested labiaplasty surgery is not medically necessary for treatment of this patient. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Based on the medical information received for review, the patients labia are within normal limits of size and are not abnormal structures. The patients labial size does not represent a congenital defect, a developmental abnormality, or a result of trauma, infection, tumors, or disease. Moreover, a labiaplasty would not be performed to improve function or provide a more than minimal improvement in the patients appearance. Therefore, the requested labiaplasty surgery is not reconstructive in nature for treatment of this patient. All told, the requested labiaplasty surgery is not medically necessary and not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested labiaplasty is not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with an orthopedic surgeon for evaluation of the enrollees left knee and right hip pain. Findings: The physician reviewer found that based on the available documentation, the requested consultation with an orthopedic surgeon is medically necessary and appropriate for further evaluation and treatment of this patients hip condition. The provider reports that the patient has longstanding symptoms interfering with daily activities and sleep despite routine symptomatic treatment including extensive independent exercise and stretching and supervised physical therapy as well as chiropractic care. Evaluation has included multiple sets of x-rays. With the presence of longstanding and limiting symptoms around a major joint, consultation with an orthopedic surgeon after failure of initial treatment directed by the primary care provider is medically necessary and appropriate. Final Result: The reviewer determined that the referral is medically necessary for evaluation 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 30-year-old female enrollee has requested for breast thermography for evaluation of her condition.   Findings:  Three physician reviewers found that according to the American Cancer Society (ACS), thermography is not effective as a screening tool for the early detection of breast cancer. The American College of Radiology does not advocate for the use of breast thermography. The gold standard imaging exam for breast cancer screening continues to be mammography. Ultrasound and breast magnetic resonance imaging are useful adjuncts in select patients. There is no scientific evidence to support the use of breast thermography.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for septoplasty and rhinoplasty revision. It takes at least one year to recover from rhinoplasty, and in patients with thick skin, it can take longer. At this time, revision surgery is premature. Additionally, the operative plan is unclear. The patient was evaluated by two providers. The first provider noted the septum to be midline and the dorsum improved. The provider did not provide an operative plan or any indication of need for revision. The second provider noted valve collapse, a septal deviation and inferior turbinate hypertrophy. While correction of valve collapse has been shown to improve nasal breathing, the patient had been treated with nasal steroids and reported their breathing was improving in March 2018. Given these findings, the requested surgery is not medically necessary. Further, the requested surgery is not reconstructive in nature based on the available documentation. Although the patient reports that they are not satisfied with their  appearance, the records do not document the presence of an abnormal structure. In addition, there is a lack of documentation that the patient has a functional problem that would be addressed with revision surgery. Further, there is no indication that the requested surgery would result in more than a minimal improvement in the patients appearance. All told, the requested septoplasty and rhinoplasty revision is not supported as reconstructive in nature or medically necessary. Final Result: The reviewer determined that the requested surgery is not medically necessary and it not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in otolaryngology and 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: Overturned

The patient is a 48-year-old female with a history of polymenorrhea, pelvic pain, and significant fibroids. The submitted records indicate that on ultrasound the uterus is enlarged to 13.7 x 4.2 x 4.9 cm with a 3.4 cm fundal fibroid and a 6 cm pedunculated fibroid; in addition, there is present a 0.6 cm cyst adjacent to the endometrium. The records provided do not document the extent of the patients bleeding, whether she has become anemic as a result of her bleeding or whether she has experienced pelvic pain. However, based upon other documentation submitted, it appears the patient has had long-term polymenorrhea, which has resulted in anemia. In addition, the patient indicates she has pelvic pain, which causes recurrent work absences. There is no reference in the submitted records as to whether an endometrial biopsy was performed.The patient has requested authorization and coverage for a total abdominal hysterectomy. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.ACOG criteria for the definitive surgical treatment of fibroids (i.e., hysterectomy) requires: the presence of a uterus enlarged to 12 weeks or greater; profuse bleeding lasting more than 7 days or repetitive periods of less than 21-day intervals or anemia due to blood loss; and pelvic discomfort caused by fibroids, e.g., chronic lower abdominal, pelvic or low back pain and back pressure. The patient meets the criteria for a hysterectomy. Her uterus is documented on ultrasound to be greater than 12 weeks size and she has demonstrated polymenorrhea. Furthermore, generally women of similar physical size as this patient with fibroids of similar size as this patient often experience significant symptoms. Moreover, it appears the patient is probably at or approaching menopause. The average age for menopause in the United States is 51+ years and women with fibroids often experience later onset of menopause. In light of these findings, a hysterectomy is medically appropriate and indicated for this patient. The patient should first undergo an endometrial biopsy to rule out cancer.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested coverage for a left knee anterior cruciate ligament (ACL) derotation brace for treatment of the enrollee status post ACL reconstruction and partial medial meniscectomy. Findings:  The physician reviewer found that the mainstay of therapy following ACL reconstruction is physiotherapy with a focus on recovery of strength, range of motion and agility.  When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion is restored (Shelbourne, et al.).  A neoprene sleeve can be used as an option for additional support (Birmingham, et al.). Despite some early recommendations (based on low-grade literature) for functional ACL bracing post-operatively (Marans, et al.) subsequent literature has not established its efficacy. A custom ACL brace has not been proven in the medical literature to be an effective intervention for this condition. Birmingham and colleagues published the results of a large scale randomized, controlled clinical trial, concluding that, `A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction.` Overall, there is insufficient reliable evidence in the medical literature that would support the medical necessity of an ACL derotation brace for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested intensive outpatient treatment, psychiatric child and adolescent treatment services for medical treatment of the enrollees obsessive-compulsive disorder.  Findings:  The physician reviewer found that the patients obsessive-compulsive disorder was causing functional impairment in her social and academic spheres, which represent critical domains for adolescents negotiating their second individuation and identity formation.  Her provider recommended intensive outpatient services, which is a level of care endorsed by the American Psychiatric Association for the treatment of obsessive-compulsive disorder.  The patient had been making progress with the active treatment.  However, she had difficulty decompressing her psychiatric burden outside of the therapeutic setting, and thus continued to struggle.  In this patients case, the services at issue were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, intensive outpatient treatment, psychiatric child and adolescent treatment services, were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Genotropin 0.8 mg/0.25 mL syringe, alternating 0.8 md sq. daily. Findings:  The physician reviewer found that the request for Genotropin 0.8 mg/0.25 mL syringe, alternating 0.8 md sq. daily is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient meets criteria for GH deficiency and GH therapy is clinically indicated. However, there is a lack of documentation demonstrating that the patient is allergic to the Health Plans preferred brand or that he was tried alternative brands that resulted in an allergic reaction. Thus, the medical necessity for brand name of Genotropin 0.8 mg/0.25 mL syringe, alternating 0.8 md sq. daily has not been established as medically necessary for treatment of the patients medical condition. 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 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.