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

Nature of Statutory Criteria/Case Summary: An enrollee has requested epidural steroid injections for treatment of the enrollees medical condition. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The use of epidural steroids for spinal stenosis has been shown to be not efficacious.  Randomized controlled trials have indicated that epidural steroids do not provide significant and sustained pain relief.  Further, this patient does not have signs of lumbar radiculopathy.  Her straight leg raising tests are negative bilaterally, and there is no sensory loss or loss of reflexes.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.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 physician 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for speech therapy. While the patient appears to have plateaued in his speech therapy progress, it is important to note that significant delays in expressive and receptive skills persist. Direct one-to-one intervention with a speech language therapist (SLT) can be effective for all areas of language for older children with developmental language disorders. Thus, direct SLT services should be available for school-aged children with developmental language disorders, including older children and adolescents with pervasive difficulties. It is also important to note that empirical evidence suggests that early interventions for children with developmental disabilities can promote greater achievement of functional potential. Consequently, there is a growing demand for rehabilitation services, beginning early, which encompass strategies of prevention, remediation and compensation to maximize a patients function in all activities. Therefore, speech therapy services are medically necessary for treatment of this patient.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 subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 44-year-old female enrollee has requested acute inpatient rehabilitation services for the treatment of the her paraplegia. Findings:  The physician reviewer found that it appears that the patient had a complex inpatient course. At the time of her acute rehabilitation admission the patient had good strength and function in her right upper extremity, but no use of her left upper extremity or her bilateral lower extremities. She also had multiple cognitive issues. An acute-level rehabilitation program was indicated at that time. However, the patient had been thoroughly evaluated and home exercise/stretching programs could have been established. Her equipment needs were identified and a wheelchair had been ordered. It does not appear there were other major goals still outstanding that would require an extension of her acute inpatient rehabilitation stay.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested  for laser hemorrhoidectomy for treatment of his hemorrhoids. Findings:  Two physician reviewers found that the treatment of choice for advanced hemorrhoids, refractory to topical treatment, is surgical hemorrhoidectomy or band ligation. Other modalities such as radiofrequency ablation and laser hemorrhoidectomy are also being evaluated. There are some small studies available in the peer-reviewed journals that have demonstrated good results with laser hemorrhoidectomy. However, there are no large clinical trials comparing the safety and efficacy of laser hemorrhoidectomy with conventional surgical hemorrhoidectomy. At the present time, laser hemorrhoidectomy is not considered the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested speech therapy for the treatment of the enrollees speech production. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best (Nelson and colleagues). According to a Cochrane Database meta-analysis of 25 studies by Law and colleagues, approximately 6% of children have speech and language difficulties. These reviewers concluded that this meta-analysis showed a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.  This patient demonstrates articulation delay, and her skills fall significantly below those of other children her age. These deficits negatively impact her ability to communicate effectively with peers and adults. Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested residential level of care services for treatment of his substance use disorder.  Findings:  The physician reviewer found that this patients records describe a significantly impaired, chemically dependent young man. He has failed less restrictive levels of rehabilitation and inpatient detoxification. Although opioid dependence is generally treated on an outpatient basis with partial agonist medication, this patient was not treatable outside of a controlled and structured environment with supervision as provided at the 24-hour level of care. When he voluntarily submitted to a residential program, this not only gave the patient access to a medically necessary treatment intervention, it also was the lowest level of care that could have been potentially successful at this stage in the progression of his chemical dependence. This conclusion is consistent with the placement criteria and treatment guidelines published by the American Society of Addiction Medicine (ASAM). For the reasons discussed above, I have determined that the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center (RTC) for treatment of enrollees behavioral health condition.  Findings:  The physician reviewer found that per the submitted documentation, the patient is both medically and psychiatrically at high risk at this time. Thus, the patient requires continued residential treatment center (RTC) services to avoid risk of serious harm or complications. All told, the services at issue were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewers determined that the services at issue were and 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 psychiatry with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested a full-body PET scan for an evaluation of her thoracic spine lesion. Findings:  Three physician reviewers found that the request for a PET scan in this patient should be denied. If a destructive lesion was suspected, a radionuclide bone scan with SPECT would have been the procedure of choice. If this exam proved negative, a malignant process would be highly unlikely particularly in light of no known primary malignancy. Also, no attempt was made to evaluate the T8 level on a CT of the chest. Such evaluation could have shed some light on the potential possibilities at this level. PET scans are not utilized routinely as a means with which to evaluate incidental findings on imaging studies absent a history of malignancy.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the water circulating cold pad with pump for medical treatment of her status post knee surgery.  Findings:  Two physician reviewers found thatthe standard of care post-operatively following a knee arthroscopy is an ice pack used four to six times daily for the first two to three days. However, there is support for continuous flow cryotherapy following a total knee replacement (Adie, et al). The patient did not undergo a total knee arthroplasty. Based on the clinical documentation submitted, and the above mentioned peer-reviewed literature, the water circulating cold pad with pump was not likely to be more beneficial for the treatment of the patients medical condition than the available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested speech and language therapy for treatment of the enrollees possible infantile spasms.  Findings:  The physician reviewer found that recently, the Infantile Spasms Working Group (ISWG) established guidelines for diagnosis and treatment of patients with this condition. The ISWG found a need for a comprehensive approach for optimal management of children with IS, including access to and evaluation by a variety of professionals, including child neurologists, pediatricians, psychiatrists, rehabilitation services (physical, occupational and speech therapy), nurses, vocational rehabilitation counselors, neuropsychologists, social workers, and pharmacists. As such, speech and language therapy is an important part of a thorough treatment regimen for patients with IS. This patient faces significant barriers to effective communication in social, educational and home environments due to disabilities resulting from infantile spasms and seizure disorder. A work-up has not revealed an etiology of these problems, but she certainly has neurological deficits as a result, including profound speech and language delay. However, speech and language therapy offered in the school setting usually focuses on educational goals. Thus, private speech and language therapy, provided by professionals with expertise in working with young patients with IS generally offers a more widespread approach. These experienced providers address communication skills in all aspects of daily living. Since functional language skills are essential to help these children express their needs and wants in a variety of environments, the requested speech and language therapy is medically necessary for treatment of this patients condition.
Appeal type: Urgent Care
Decision: Overturned

A 26-year-old female enrollee requested services for the treatment of her medical condition. Findings:  The physician reviewer found that there are known possible risks associated with oligohydramnios including cord compression at labor and fetal distress. The etiology of progressive oligohydramnios can also be uteroplacental insufficiency, which at term warrants delivery. Because of her malpresentation, this patient required cesarean section as the mode of delivery. Immediate cesarean section was reasonable and indicated because of the possible risks of unmonitored labor and oligohydramnios (cord compression) that could have occurred with transfer.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested participation in a clinical trial for treatment of his medical condition.   Findings:  Two physician reviewers found that often there is no better therapy to offer a patient than enrollment onto a well-designed, scientifically valid, peer-reviewed clinical trial. According to the National Comprehensive Cancer Network (NCCN) guidelines the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Per NCCN guidelines, the first recommendation for patients over 60 years of age is a clinical trial. In sum, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested services are 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

The parent of a four-year-old male enrollee has requested speech therapy and social skills group therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that patients with Autism Spectrum Disorder (ASD) have deficits in social communication and treatment by a speech and language pathologist is appropriate (Myers and colleagues). The practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) indicates that the treatment of ASD requires various treatment modalities such as pharmacotherapy, special education, speech and language therapy, occupational therapy, and behavior therapy. An article by Bellini and Peters noted that young patients with ASD benefit from intensive, early intervention that focuses on increasing the frequency, form and function of communication. For these reasons, I have determined that speech therapy is medically necessary for management of this patients medical condition. With regard to social skills group therapy, as noted by Bellini and Peters, multiple strategies are often needed to address these unique deficits. The authors recommend various modalities including video modeling, coaching, employing social stories, social problem solving, behavior rehearsal, feedback and reinforcement. They suggest that effective strategies usually involve multiple settings. The overall effectiveness of social skills group therapy for young patients with ASD is still in its infancy, as reported by White and Keonig. Given that there are multiple strategies available to address social skills deficits in young patients with ASD, the medical necessity for social skills group therapy has not been established for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male requested authorization and coverage of thalidomide for treatment of ocular melanoma with metastasis to the liver.  The health plan denied the enrollees request indicating that treatment with thalidomide is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three-physician reviewers concluded that thalidomide is not likely to be more beneficial for treatment of the enrollees ocular melanoma with metastasis to the liver than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female who underwent an in vitro fertilization (IVF) cycle in August of 2005. Her diagnosis is not clear from the record, but it is assumed that she had a history of infertility given the notation of diminished ovarian reserve. Prior to the initiation of the IVF cycle the patient was tested for immunologic abnormalities. Serum %CD56, %CD19+ cells, and CD5+ levels were elevated, serum antithyroid antibodies were positive and a serum IgM for phosphoethanolamine was borderline positive. The patient underwent the IVF cycle which yielded 13 eggs and 10 fertilizations. There were seven embryos transferred and three discarded. The patient was offered and given IVIG treatment prior to the embryo transfer. Serum BHCG levels in September 2005 were each 8, and negative in the end of September 2005. The patients request for reimbursement for the cost of the IVIG therapy was denied by the Health Plan citing a lack of medical necessary.The 2004 Practice Committee Opinion of the American Society for Reproductive Medicine concluded that IVIG therapy for recurrent miscarriage is an experimental treatment and should only be offered in the context of a research study.  IVIG treatment for reproductive disorders in general and recurrent miscarriage in particular, has been investigated in small studies over the past decade in Europe and the United States. Although a few of the studies showed modest benefit in properly characterized patients with recurrent pregnancy loss, there is limited peer-reviewed, published work in this area and the efficacy of IVIG therapy in couples with infertility not been clearly established. A consensus of support for IVIG treatment is lacking and additional randomized, controlled trials are needed to determine if there is a benefit in reproductive outcomes. Currently, there is no convincing evidence in the medical literature that IVIG treatment is efficacious in a patient with infertility, whether or not the patient is undergoing in vitro fertilization. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested computer-assisted surgical navigational procedure for musculoskeletal procedures (CPT 20985) for treatment of her left hip pain.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment modalities.  The patient has severe left hip pain and a left total hip arthroplasty is planned.  Although cup inclination may be more consistent with the use of computer navigation, there is a lack of clinical data supporting its use.  Per the current medical literature, outcomes have not been shown to be improved with this technology over standard techniques.  Of note, computer navigated procedures often involve an increase in operative time.  All told, computer-assisted surgical navigational procedure for musculoskeletal procedures (CPT 20985) is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old male who has a diagnosis of multiple sclerosis with associated chronic fatigue and pain. He received physical therapy. The patients provider recommended continued physical therapy three times a week. The Health Plan has denied coverage for physical therapy the patient received, as well as authorization for additional physical therapy on the basis such services are not medically necessary. The Health Plans denial should be upheld. Physical therapy was being used for maintenance with no functional improvement goals expected. There is no medical indication for additional therapy. The patient should have a clear understanding of a home program based on the amount of supervised physical therapy he has received and should be able to participate in an independent program. Therefore, I have determined the medical necessity of the therapy at issue has not been established. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for continuous glucose monitor (CGM).A CGM system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Over the last decade, CGM systems have been demonstrated to be clinically valuable. A CGM system can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. CGM systems have been confirmed to be a safe modality, with high accuracy in glycemic values and a low complication rate. Therefore, the requested CGM is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested device is 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 endocrinology, diabetes, and metabolism 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.