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 readmission to custodial level of care.The records indicate that the patient has had spinal issues and a left elbow fracture in late 2020 that was surgically repaired. She has been at an independent living facility since March 2021. There is no documentation of impairments or ongoing medical issues that establish the need for a higher level of care than an independent living facility. The facility has been working with the patient and her family to return to the community, but there are no indications in the records that the objections to returning to the community are based on any medical issues. The medical necessity of a return to a facility level of care is not established. Therefore, readmission to custodial level of care is not medically necessary for the treatment of the patients medical condition.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 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: Upheld

The representative of a 27-year-old female has requested 10 hours of direct ABA services per week with 2 hours per month of supervision and 2 hours per month of planning and assessment for treatment of autism.  Findings:  The physician reviewer found that although autism is a life-long condition, the literature pertaining to the treatment of adults with autism is quite limited. The bulk of ABA literature is concentrated in its application to young children. The medical communitys customary and usual prescription for autistic children is ABA therapy and the medical literature strongly supports the use of ABA therapy for the treatment of children with autism. However, when reviewing ABA as applied to adults, there is limited literature substantiating its favorable effect on the adult population. This is particularly true in individuals who carry a co-morbid diagnosis of autism spectrum disorder and intellectual disability, such as this patient. In this patients case, she has failed to demonstrate significant improvement following multiple years of individual ABA therapy. Comparison of her most recent progress report seven months ago, and the extensive evaluation performed seven months prior to that, shows no significant improvement, despite the mention of some positive behavioral changes in the progress report. Thus, given the lack of significant clinical evidence demonstrating improvement with ABA therapy, the medical necessity of the requested services has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested for a chest computed tomography angiography (CTA) for evaluation of his heart condition. Findings:  Three physician reviewers found that there are published guidelines from the American College of Cardiology (ACC) regarding the appropriate use of cardiac CTA. In this case, the patient does not have symptoms of chest pain, but has risk factors for coronary artery disease (CAD). His calcium score is elevated (greater than 400). Other ACC guidelines (Brandis) alternatively recommend stress perfusion testing in this setting. This patient falls under Table 4. Risk Assessment with Prior Test Results, Asymptomatic, of the 2005 SPECT guidelines. Given his CCT score of greater than 400, he falls under Indication 27 Asymptomatic, Prior Coronary Calcium Agatston Score, Agatston score greater than or equal to 400. This indication has an appropriate recommendation for the use of stress perfusion (and not cardiac CTA) testing as a next step.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Odomzo (sonidegib) for treatment of his medical condition. Findings:  Two physician reviewers found that Odomzo is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has received prior treatment with the sonic hedgehog inhibitor Erivedge (vismodegib). According to the National Comprehensive Cancer Network (NCCN) guidelines, results from phase I-II trials with small BCC sample sizes (N < 40 patients) have shown that itraconazole and saridegib can elicit responses in patients with BCC, although not in patients who previously received vismodegib (n = 12 patients tested). Thus, treatment with Odomzo (sonidegib) is not likely to have a response since it also shares the same hedgehog pathway as vismodegib. Therefore, treatment with Odomzo is not 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 medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   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: Upheld

The patient is a 44-year-old female who is 52 weighing 125 pounds with a breast size of 38C. She had a breast reduction in 1994. She is complaining of upper shoulder and neck pain as well as breast discomfort with aerobic activity. She has been receiving chiropractic for her neck and back pain without sustained relief. She is requesting authorization for breast reduction surgery.The patient previously underwent breast reduction in 1994 but feels her breasts still interfere with her ability to exercise, and are unsightly. The submitted photographs do not depict pathologic macromastia. The physical examination does not describe typical findings that would satisfy the accepted medical necessity criteria for breast reduction coverage. The amount of tissue that could be removed would make little difference in the total weight and distribution of breast tissue as it pertains to the patients symptoms. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression.   Findings:  Two physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and gives guidelines for its use. Additionally, the American Psychiatric Association (APA) has now included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. This patients records indicate that he has been tried on antidepressants without benefit. However, there is no information in the record to document the specific antidepressants tried, what dosages were used and the duration. Further, there is no indication that augmentation strategies have been tried, such as mood stabilizers, thyroid, or stimulants. The patient has not reportedly received cognitive behavioral therapy (CBT) psychotherapy or electroconvulsive therapy (ECT) for treatment. In summary, although TMS is an approved treatment for treatment-resistant depression, there is inadequate documentation that standard available standard therapies were tried and failed prior to treatment with TMS.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for whole breast ultrasound.Findings: Two out of three physician reviewers found that the authorization and coverage for whole breast ultrasound is likely to be more beneficial for the enrollee than any available standard therapy.Although ultrasound has a role in screening for breast cancer, most of the literature involves breast ultrasound as an augmentation to routine mammography. When a lump or suspicious abnormality is discovered on a routine mammography, a targeted breast sonogram is the next step prior to biopsy. Breast sonography is the best means to distinguish between cystic and solid lesions. The issue of a whole breast sonography as a screening tool is an entirely different issue. Kaplan states, ABUS [automated breast ultrasonography] is a developing technology that has been recently approved by the U.S. Food and Drug Administration for use in screening for breast cancer as an adjunct to mammography. The issue, in studies supporting the use of ultrasounds, is that automated whole breast sonography was performed as an adjunct to mammography, not as a replacement. Berg and colleagues have shown an increased detection rate of occult breast cancer in a screening population when sonography is added to routine mammography. There are clearly limitations for any type of sonography in evaluating breasts. Specifically, automated whole breast ultrasound (AWBU) cannot diagnose microcalcifications and is marginal in evaluating the deeper portions of the breast. As in this patient, once an abnormality is detected, one will generally resort to an additional hand-held targeted sonogram. Further, when a prior whole breast sonogram is negative, a whole breast ultrasound is not an effective means to screen for breast cancer.For this patient, the screening procedure is apparently only for the sonogram. There is no accompanying mammogram, and there are no reported direct breast symptoms. Whole breast sonography is not a replacement for mammography. Therefore, a whole breast ultrasound is not likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested reimbursement for residential level of care services and partial hospitalization program (PHP) level of care services for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient is a small statured woman who was at her highest weight at 100% of her ideal body weight (IBW) on admission. The patient indicated that she was to menstruate and did not use laxatives or purgatives or over exercise. Her mood symptoms tested out at minimal levels and her predominant concerning behavior was her self-cutting. Applying the practice guidelines from the American Psychiatric Association (APA), the RTC services were not medically necessary as the patients records do not document any medical instability, controlled psychiatric co-morbid conditions, or imminent weight loss that will predictably lead to medical instability. Similarly, the patient did not have the severity of symptoms recommended for treatment in a PHP level of care without evidence of significant restricting. Moreover, the patients treatment goals did not include re-feeding and weight restoration, and focused predominantly on behavioral issues and family conflict that could have been safely and adequately managed through a conventional outpatient mental health intervention. Accordingly, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. Findings:  The physician reviewer found that the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. The clinical documentation submitted for review does not demonstrate the medical necessity of service delivery in a 24-hour supervised setting for the diagnosis of sedative, hypnotic or anxiolytic (benzodiazepine) use disorder during the dates in dispute. The patient presented with significant medical co-morbidity and complex chronic pain which represented the driving force for her treatment. However, she did not have a psychiatric condition that would have necessitated a residential treatment setting. She was married and had a supportive spouse and safe housing. She was reluctant to consider the notion that she had an addictive illness. There was no evidence of co-addiction with other substances. She had no history of complicated withdrawal, blackouts or seizures. She did not report recent overconsumption of the benzodiazepines, while neither medication was excessively dosed. Her last use of clonazepam was four days prior to admission and her last use of diazepam, which has a long half-life that facilitates auto-tapering in many instances, was three days prior to admission.  Upon presentation to the treatment facility, the patient was non-distressed and afebrile with a blood pressure of 120/88 and heart rate of 73 beats per minute. During the episode of illness, the patient had no prior history of chemical dependency treatment such as community programming, outpatient counseling or detoxification efforts, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. Current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In addition, there is a lack of evidence to suggest that comprehensive, evidence-based chemical dependency services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections for the left knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patients options are limited. He has tried and failed cortisone injections, platelet-rich plasma injections, and physical therapy. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Euflexxa injections for the left knee are medically necessary for the 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 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 52-year-old female enrollee has requested hip resurfacing surgery for the treatment of her right hip degenerative joint disease (DJD) secondary to osteoarthritis. Findings:  Two physician reviewers found that there is a general agreement that more prospective studies of hip resurfacing surgery need to be completed. Hip resurfacing procedures have been performed for many years, but have been shown to have many problems associated with them. Changes in operative procedures and implant design and materials have led to an increased interest in resurfacing, since there are some theoretical benefits as compared to replacement, which has been the standard procedure for some 30 years. However, there are still questions to be resolved such as the longevity of the procedures results and the long-term effects of metal ionic spread, and the present metal-on-metal prostheses associated with this concern. In addition, patient selection is of great importance, since the choice of procedure can vary with age, sex, and bone stock and the majority of serious complications in a recent study occurred in women of all ages and men over the age of 55. All told, there is insufficient evidence of the efficacy of hip resurfacing to support its use at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested  intensive outpatient substance abuse treatment for treatment of the enrollees cannabis dependence. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  In this patients case, the records note psychiatric comorbidity and budding antisocial behaviors.  This patient was having significant impairment across multiple domains of functioning and required comprehensive specialty care to prevent further psychiatric morbidity.  As of the date indicated, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting.  On the subsequent date, the patient punched a wall to deal with his stress and was unable to articulate alternative strategies.  The current medical evidence supports intensive outpatient substance abuse treatment in this clinical setting.  The treatment provided was and is reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, continued intensive outpatient substance abuse treatment from the date indicated forward was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male has requested extensive vision therapy sessions by an optometrist specializing in binocular vision disorders and vision therapy for treatment of his binocular vision disorder, unspecified.  Findings:  The physician reviewer found that conditions such as binocular vision dysfunction accommodative infacility (367.4) and ocular motor dysfunction (Pursuit 379.58, Saccadic 379.57) are successfully treated with orthoptic therapy (see Suchoff and Petito). The above conditions often present with symptoms of blurred vision at near, discomfort, strain and fatigue associated with near tasks, difficulty focusing from far to near, as well as loss of place while reading. The goal of orthoptic therapy is to stimulate and normalize accommodative, vergence and oculomotor abilities. The endpoint of orthoptic therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. Review of the relevant literature demonstrates a solid base of research supporting vision therapy as an effective treatment mode for vergence, accommodative and oculomotor deficiencies (Scheiman and Wick). Vision therapy has been a viable treatment for binocular vision and oculomotor disorders since the 1950s. Orthoptic treatment for oculomotor, accommodative and binocular vision dysfunction is the standard of care for children and adults diagnosed with these conditions. Typical treatment duration for this patients conditions is 12-24 sessions (Scheiman and Wick). The number of therapy sessions varies according to patient age, motivation and compliance. The 40 visits requested do not meet standard criteria. Standard treatment consists of a maximum of 24 sessions of vision therapy visits which should be sufficient for treating this patients deficits. Therefore, a portion of the requested therapy (up to 24 sessions) is medically necessary for treatment of the patients medical condition. Additionally, any optometrist who implements vision therapy in their practice can appropriately treat this patients commonly seen diagnoses. No evidence has been provided which demonstrates that the patients vision therapy must be performed by an optometrist specializing in binocular vision disorders and vision therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee requested rectus diastasis repair for medical treatment of the enrollees rectus diastasis and abdominal pain.  Findings:  The physician reviewer found that the requested procedure is not medically necessary for treatment of the patients medical condition. The surgeon recommended weight loss and has not provided additional justification for intervention on a functional basis. There are no photographs to document an extraordinary condition. In addition, there does not appear to be a significant pannus to suggest that there is a functional deficit such as chronic intertrigo, ulcerations and/or lower back pain related to the size of an overhanging pannus. Thus, diastasis rectus repair is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested reimbursement for Lexapro for treatment of the enrollees depression. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue in this patients case.  The Health Plan has offered formulary alternatives, including citalopram, fluoxetine, paroxetine, and sertraline.  Lexapro tends to be a well-tolerated medication with good efficacy.  However, there is a lack of well-designed, controlled studies demonstrating its superiority to the four selective serotonin reuptake inhibitors offered by the Health Plan.  There is adequate medical evidence supporting the use of the alternative medications offered by the Health Plan in this patients case.  The submitted medical records do not demonstrate that the patient has tried and failed treatment with sertraline.  Sertraline is an accepted treatment alternative in this clinical setting.  All told, Lexapro was not medically necessary for the treatment of this patient.