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

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing level of care. Findings:  The physician reviewer found that  The patient does have a programmable shunt placed due to hydrocephalus.  Programmable shunts may potentially provide some benefits to avoid some of the mechanical complications associated with fixed rate shunts.  Generally, there are no set adjustment protocols for patients who have shunts with programmable valves, and this management is clinically determined.  There is a lack of objective indications in the records documenting that the patients shunt requires close monitoring in a hospital setting on an ongoing basis.  Based on the available records, skilled therapy and nursing services on an inpatient level would not be reasonably expected to impart a marginal benefit on the patients health or functional outcomes or clinical course in comparison to a basic restorative nursing program for range of motion, strengthening and activities at a custodial level of care. Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician reviewer is board certified in physical medicine and rehabilitation 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

A 39-year-old male enrollee has requested a consultation with an endocrinologist for possible growth hormone therapy for treatment of his medical condition. Findings:  The physician reviewer found that from an endocrine standpoint, there are two issues that are unknown in this case. First, there is the question of what is causing the patients low testosterone levels. This could be primary hypogonadism versus secondary or hypothalamic hypogonadism. An endocrinology consultation will help distinguish between the two categories, which is important because the management is different in each situation. Second, this patient did not respond to testosterone supplementation. This could be indicative of additional problems, and thus, it should not be assumed that his condition is due to low testosterone levels. An endocrinology consultation is important to rule out not only the cause of low testosterone levels, but also whether other endocrine systems are affected and could be cause of the patients symptoms.In summary, without an accurate diagnosis this patients condition cannot be properly treated and the patients primary care physician has requested an endocrine consultation. This specialty evaluation is medically necessary as his condition has not responded to the treatment prescribed thus far.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for gammaCore vagus nerve stimulator (VNS). The American Headache Society (AHS) position statement on integrating new migraine treatments into clinical practice states that, neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy. Researchers reviewed the evidence of noninvasive VNS for the treatment of migraine. The authors concluded that patients with migraine who experience two or more headache days per month and remain dissatisfied with their current treatment are the best candidates to try gammaCore. In addition, the FDA has approved gammaCore VNS for the acute treatment of migraine and cluster headache. In this case, the patient has migraines that have not responded to multiple oral medications. She has tried gammaCore in the past, which resulted in improvement in migraine frequency and severity. The AHS position statement and medical studies support treatment with gammaCore for this patients migraines. Therefore, the requested GammaCore VNS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a hospital stay. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post motor vehicle accident with intracranial hemorrhage.The hospital stay was not medically necessary for treatment of the patients medical condition. In this case, the patient was stable. He was awake and ambulating.  The documentation does not support that he had any complications, active infection, seizures or change in mental status. He was tolerating an oral diet without any swallowing difficulties. He had a thromboembolic work-up for the stroke and was receiving rehabilitation services. His strength was at a functional level and he did not appear to require any new assistive devices. He could have been safely discharged to receive further services at a lower level of care.Final Result: The reviewer determined that the services at issue were 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 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 parent of an enrollee has requested authorization and coverage for 15 hours of applied behavioral analysis therapy per week. The patient has been receiving these services on-going and has reportedly made significant gains in this time. While there are still goals to be addressed, the provider has indicated that these goals can be met through a lesser amount of hours of ABA therapy per week and a significant amount of supervised hours over a six-month period. The Behavior Analyst Certification Board (BACB) indicates that service intensity should be dictated by the patients needs and results of the assessment. The assessment provided, recommends that the service intensity lessen to 10 hours of direct ABA services per week. Thus, the requested 15 hours per week of direct ABA therapy is not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested amount of services is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a board certified psychologist and is a board certified behavioral analyst 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 37-year-old male with a history of daytime fatigue, anxiety, and depression. In evaluation of these symptoms, two separate polysmonographies have been completed. The first was a home study performed in September 2003. The patients provider notes the patients AH1 was 11 at that time. A second sleep study was performed in an observed situation in April 2004. The patients AHI at that time was 7.7 with the caveat that the technologist turned the patient on his side during the exam and the patients AHI while he was supine was 33. Oxygen saturation nadir of 89% was also noted. Physical examination of the patient by one otolaryngologist described the tonsils as 1+ and the oropharynx to be Mallampati class II. On fiberoptic endoscopy collapse of the nasopharynx and oropharynx was noted during the Muller maneuver. Examination by a second opinion physician documented the tonsils to be 2+ and an enlarged uvula. The patient has had an adequate trial of CPAP, having tried three different masks. This was not tolerated as the masks were inadvertently pulled off at night. A trial of use of an oral appliance yielded similar results. At this time authorization for tonsillectomy and palatopharyngoplasty has been requested. The Health Plan has authorized the tonsillectomy, but indicates palatopharyngoplasty is not medically necessary for treatment of the patients medical condition. The patient has documented mild or moderate obstructive sleep apnea (OSA), depending upon which numbers are used. The most common standards of care being used are allowance for treatment of OSA if AHI is greater than 15 in all cases. If the patients AHI is between 5 and 14, treatment is generally allowed if there is concomitant documentation of excessive daytime sleepiness, impaired cognition, mood disorder or insomnia, hypertension, ischemic heart disease or stroke. This patient meets these criteria. He has an AHI of either 7.7 or 11 and has documented anxiety and depression, having been treated by a psychologist with medication for these diagnoses. The patient also meets medical necessity criteria for surgery as treatment for OSA in that he has tried and failed CPAP. Current standard of care for stage one surgical treatment of OSA includes palatopharyngoplasty in conjunction with tonsillectomy, if the latter structures are present and hyperplastic. It is also becoming more common to include genioglossus advancement or tongue base reduction in this first stage, as success rates in treatment are repeatedly being shown to improve with these added procedures. Except for in children with adenotonsillar hyperplasia, Tonsillectomy alone is not an accepted, standard of care treatment for OSA except for children with adenotonsillar hyperplasia Given these findings, palatopharyngoplasty is medically appropriate and indicated for treatment of this patients OSA.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services. Findings: The physician reviewer found that , the patient presented to urgent care with reports of a rash for one week. She denied any fever, chest pain or shortness of breath. The patients vital signs and lung exam were normal. A skin rash was noted. No emergent condition was identified and no emergent treatment was provided. The patient presented to urgent care with reports of a cough and sore throat. Her vital signs were stable. Heart and lung exam were also normal. The patient was discharged with a prescription for an antibiotic. No emergent condition was identified and no emergent treatment was provided. In sum, there is no documentation to support that the patient received emergency medical services on the dates of service at issue. Final Result: The reviewers determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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

The patient is a 58-year-old female who felt a small nodule in the inferior medial left breast. Mammogram in August 2004 was negative. In August 2004, the patient was evaluated by her clinician who performed an ultrasound and a core biopsy of a 1 cm mass at 7oclock. The pathology was fibroadipose tissue. In September 2004, the patient then underwent an excisional biopsy. The pathology results were benign nonproliferative fibrocystic changes. There was no evidence of malignancy.In a follow-up appointment with her clinician in November 2004, three fatty nodules were palpated at 9 oclock in the left breast. An MRI was ordered for further evaluation, which was performed in mid-November 2004. The patient has no history of breast cancer and has been on estrogen for many years. The Health Plan has denied reimbursement for the MRI at issue on the basis it was not medically necessary for evaluation of the patients medical condition.There are several indications for MRI of the breast, which include pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants.Since this patient had a relatively recent mammogram, ultrasound, ultrasound-guided biopsy, and excisional biopsy of the left breast, a new malignancy in the breast would be very unlikely. A repeat left breast mammogram and ultrasound and follow-up clinical exam would have been appropriate before considering MRI and possibly another biopsy. Given the specifics of this case, an MRI was not medically warranted for this patient.Based upon the information set forth above, I have determined that the MRI at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested authorization and coverage for laparoscopic excision of endometrioses, lysis of adhesions, enterolysis, ureterolysis, left ovarian suspension, cervical conization, and possible left upper abdominal adhesiolysis. The Health Plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees endometriosis.  Findings:  The physician reviewer found that based on review of the available records, the patient has evidence of a recurrent right ovarian endometrioma. Her records confirm a history of an incomplete treatment of her endometriosis including drainage of a right endometrioma and endometrial implants left behind. The recurrence of an endometrioma associated with pelvic pain is an indication for a surgical procedure. In addition, the untreated endometrial implants as well as potential adhesive disease may be treated during such procedure. Therefore, the proposed procedure itself is well within the standard of care and is medically necessary. Although the surgical treatment of endometriosis may require the resection of lesions on multiple organs and the peritoneum as well as adhesiolysis, these are procedures that are within the expertise and skill of a board-certified, competent gynecologic surgeon. In complex situations when there is intestinal or urinary tract involvement, the gynecologist has the option of referring the patient to an In-Plan surgical specialist who can provide advanced care for her condition. This patient was appropriately referred to the director of a university-based pelvic pain program, partially for these reasons. This program apparently has the capability of providing multispecialty care for the patients condition including surgical care. If the patients opts for surgery, the specialist has the surgical expertise to treat this condition and also has the advantage of consulting the universitys staff of advanced surgical specialists for gastrointestinal and urologic involvement if needed. For these reasons, the requested surgery is medically necessary for treatment of the patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested Genotropin injections for the treatment of his short stature. Findings:  The physician reviewer found that this patient has been diagnosed with hypophosphatemic rickets. Stature in this disease appears to be determined by the vitamin D receptor genotype. While there are reports of metabolic benefits of growth hormone therapy, a recent meta-analysis of published studies did not confirm any clear growth benefits or studies on improved final adult height. Thus, the clinical value of growth hormone therapy in this patients case has not yet been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 12-year-old female with a history of an uncomplicated birth but global developmental delays including fine motor, gross motor (walked at 24 months) and speech delays for which she received occupational therapy, physical therapy and speech therapy as a child. She has also been diagnosed with attention deficit hyperactive disorder, anxiety and depression. She continues to have mild to moderate difficulties in language comprehension and expressive language. At issue is whether continued speech therapy for these delays is medically necessary.Upon review of the submitted therapy reports it appears little gains have been made from 2002 through 2005. Although the testing employed in each report is different, the areas of deficit are consistent between examiners. Furthermore, review of the relevant literature reveals a meta-analysis of speech and language therapy for people with primary speech and language delay. The conclusion of the meta-analysis was that the benefit of therapy on expressive syntax errors was mixed and there was less evidence that interventions are effective with receptive difficulties.Given the patients previous therapy interventions, her age, and the lack of scientific data supporting speech therapy for these types of deficits, significant improvement is not anticipated with continued speech therapy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested eribulin intravenous (IV) (mesylate 0.1 mg) therapy for medical treatment of her metastatic leiomyosarcoma.  Findings:  Two physician reviewers found that.  The patients provider recommended eribulin in the hope of rendering the patient more surgically operable.  There is sufficient support for the requested medication in this clinical setting.  Therefore, eribulin IV (mesylate 0.1 mg) therapy is likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested for abdominal panniculectomy for treatment of his excess skin. Findings:  The physician reviewer found that the records do not provide any objective medical documentation of infections or evidence that the patient has ever seen a physician for assistance with the medical management of infections.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is certainly not the case for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate saturation biopsy for evaluation of the enrollees atypical prostate biopsy results. Findings:  Three physician reviewers found that the biopsy revealed atypical small acinar proliferation (ASAP) at the left lateral apex. There was another follow up biopsy which revealed ASAP at the left apex. At this visit, he presented with elevated prostate specific antigen (PSA), hypogonadism and ASAP. He had a prostate cancer antigen (PCA) 3 test which was normal at 24. His PSA was up to 11.5. He had prostate magnetic resonance imaging (MRI), which was normal. A repeat MRI showed small suspicious areas central zone. However, according to the prostate image reporting and data system (PIRADS), the report indicated a score of 3, which is low suspicion for cancer. He had a normal rectal examination. He is on testosterone replacement therapy. The patient requested authorization and coverage for saturation biopsies to detect prostate cancer. The Health Plan denied the requested services as investigational for the evaluation of this patient. The current evidence suggests that saturation schemes are associated with a higher PCA detection rate compared to standard ones on initial prostate biopsies in men with lower PSA levels or larger prostates. On repeat prostate biopsies, the studies show broad variations throughout the literature. As such, the clinical data must be interpreted with caution. This patient has low risk of having significant prostate cancer based on his history. Therefore, saturation biopsy is not likely to show clinical benefit. If repeat biopsy is considered, it should be with MRI fusion. Therefore, the requested services are not likely to be more beneficial than other alternatives for the evaluation of this patients medical condition. Final Result: The three reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a brain computed tomography (CT) scan for medical evaluation of her narcolepsy without cataplexy.   Findings:  The physician reviewer found that review of the records does not reveal the method by which narcolepsy was diagnosed by the patients provider. The patient has a history of chronic migraines but no history of recent trauma, malignancy, infection or other red flag to support an indication for immediate imaging. The neurological consultation is pending and the neurologists evaluation and recommendation should be helpful. However, on review of the records submitted, there is a lack of findings supporting the requested CT scan of the brain as medically necessary.