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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.In the provided documentation, the patient was noted to have improvement of symptoms. The entry of the course of treatment section of the discharge summary, noted that the patient slept well and was doing better in school.  The patient was noted to have no panic symptoms.  Progress notes indicated that the patients anxiety was improved, mood stable, and she was cooperative and participating in activities.  During the time period in dispute, there was no documentation of suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical status and documentation as outlined above, at the time of the denial, the patient met CASII criteria for intensive outpatient services and not residential treatment level of care. Therefore, treatment at the residential level of care was not medically necessary for this patient.Findings:The reviewer has 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage of the medication Klonopin (clonazepam), 5.0 mg twice daily and 2.5 mg to 5.0 mg at bedtime. Breilmann and colleagues note that while benzodiazepines are frequently used in the treatment of panic disorder, guidelines recommend antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), as first-line treatment for panic disorder, particularly due to their lower incidence of dependence and withdrawal reaction when compared to benzodiazepines. The American Psychiatric Association (APA) practice guidelines for the treatment of panic disorder recommend psychosocial treatment, with the strongest evidence available for cognitive behavioral therapy. In this case, the patient has reported life stress and the records reflect symptoms that appear consistent with affective dysregulation consistent with borderline personality disorder. She is being treated with numerous medications without improvement to her anxiety and affective dysregulation. The documentation does not reflect that the patients provider has recommended a higher dosage of clonazepam. Given that benzodiazepine treatment is meant for the short-term treatment acute panic attacks, and at a low dose chronically for residual anxiety if SSRI treatment is insufficient, and that a dosage higher than that approved by the U.S. Food and Drug Administration (FDA) may carry the risk of would have significant morbidity and chance of mortality, the requested medication regimen is not medically indicated. Therefore, dosage of the medication Klonopin (clonazepam), 5.0 mg twice daily and 2.5 mg to 5.0 mg at bedtime is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Achilles tendon repair surgery for treatment of the enrollee, who is status post right Achilles lengthening procedure. Findings: The physician reviewer found that the current, evidence-based, peer-reviewed literature generally supports surgical treatment for insertional Achilles tendinopathy for patients with ongoing pain and functional limitations who have failed conservative treatment. This patient presents with a complex right foot/ankle history with ongoing pain and functional limitations in mobility. Clinical examination findings have been consistent with imaging evidence of severe Achilles tendinosis/tendinitis. An orthopedic specialist recommended consideration of Achilles reconstruction with caution based on the patients surgical history, if the patient failed to improve with the conservative treatment recommended at his consultation. While the physical therapist documented the patient failed to improve with conservative treatment the patient has not subsequently been re-evaluated by the surgeon he consulted to confirm these findings as well as that the patient remains an appropriate candidate for Achilles tendon repair surgery. As such, re-evaluation with the provider who recommended the proposed Achilles tendon repair is medically necessary at this time. If the surgeon who previously recommended the surgery is unable to re-evaluate the enrollee, the enrollee should be evaluated by another orthopedic surgeon who is appropriately qualified to perform the enrollees Achilles tendon repair surgery if the surgeon deems it to be medically necessary. Final Result: The reviewer determined that re-evaluation by the surgeon the enrollee  previously consulted with or another appropriately qualified orthopedic surgeon is medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time pending the surgical re-evaluation. 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: Medical Necessity
Decision: Overturned

A thirty-six year-old female who has breast hypertrophy is requesting authorization of bilateral reduction mammoplasty. Reviewers Findings:  The reviewing physician found that reduction mammoplasty provides the best and perhaps only chance for relief of this patients symptoms.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee is requesting authorization and coverage for a durable dental mouth guard. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. The current literature recommends that a dental provider evaluate patients for adequate periodontal health and an absence of temporomandibular joint problems prior to use of an oral appliance. This is due to the potential side effects of oral appliance therapy, which include temporomandibular joint problems and tooth mobility.  The medical records do not document that such an evaluation took place. Thus, the provision of an oral appliance would not be consistent with the generally accepted standards of care in this clinical setting. There is a lack of support for the requested device in this patients case. Therefore, the requested durable dental mouth guard is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 neurology with sub-specialty certification in sleep 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

The patient is a 59-year-old female with almost a 30-year history of diabetes mellitus type II. Her blood glucose was not controlled on a variety of oral medications. Her HgA1C in October 2004 was 9.3%. Novolog was added in the spring of 2005. The patients HgA1C dropped from 9.3% to 8.4% on metformin 1000mg twice a day, glyburide 10mg twice a day, Avandia 8mg once a day, and Novolog twice a day. The patient experienced several hypoglycemic reactions on this regimen. In the summer of 2005 Novolog was discontinued and the patient was started on Byetta 5mcg twice daily and the oral medications were continued as above. Lab results from October 2005 indicate the patients HgA1C had dropped to 7.3%. The patient has requested authorization and coverage for Byetta. The Health Plan has denied this request on the basis that Byetta is not medically necessary for treatment of the patients condition.Review of the submitted medical records reveals the patient achieved better control of her blood sugar with Byetta, metformin, glyburide and Avandia than with Novolog, metformin, glyburide, and Avandia. She did not experience hypoglycemia while on Byetta and no side effects were reported.Byetta is the synthetic version of a hormone produced by the intestinal tract. Byetta slows down digestion, stimulates insulin production and decreases post-prandial glucagon levels. The results are better blood glucose control, lower pre- and post-prandial blood sugars, decrease in appetite, and weight loss. The only side effect of Byetta is initial nausea, which usually subsides. Since Byetta is a synthetic natural hormone of the body (like insulin), there should be no contraindications with any other drugs. Clinical studies have shown that Byetta is indicated for patients with diabetes mellitus type II who take sulfonylureas and/or metformin. Thiazolidinedione derivatives (TZDs) such as Avandia, and Actos are insulin sensitizers like metformin. Studies are being conducted using TZDs and Byetta. Many endocrinologists are using Byetta in type II patients in conjunction with TZDs.The patient experienced good results with Byetta, metformin, glyburide and Avandia, leading to improvement in her health and reduction in hypoglycemia. Therefore, continuation of Byetta is medically appropriate and indicated. It would also be appropriate to consider lowering the dose of metformin, glyburide and Avandia in conjunction with Byetta.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested acute inpatient psychiatric services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient was hospitalized for a relatively short time given the severity of her symptoms upon admission. While on the unit, she continued with suicidal threats and stated a plan for carrying out these threats. The patient often required unscheduled medications. Her behavior was generally manipulative, demanding and attention seeking and she was unable to contract for safety up until discharge. While the patients symptoms suggest a behavioral disorder as well as a mood disorder, her condition was severe enough to require inpatient treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery for reattachment of tendon. Findings:  The physician reviewer found that the documentation does not support the medical necessity for the requested procedure in this clinical setting. Current peer-reviewed literature indicates that flexor tendon injuries remain a challenging condition to ensure optimal outcome and restoration of function following zone 2 repairs. Ongoing clinical and basic research have improved understanding of flexor tendon mechanics and physiology for surgical repair and rehabilitation after a zone 2 flexor tendon repair. Yet, the ideal surgical repair technique that includes sufficient strength to allow safe immediate active motion of the finger, without excessive repair stiffness, bulk or rough surfaces resulting in excessive resistance to flexion, does not exist. After optimizing the repair, the surgeon and therapist team must select a rehabilitation plan that protects the repair but helps to maintain tendon gliding. There are common secondary complications that include decreased range of motion and stiffness associated with tendon adhesions. This patient underwent left middle finger corrective osteotomy . Records documented that a zone 2 flexor tendon laceration was sustained during the procedure and the flexor digitorum profundus (FDS) tendon was repaired. The FDS tendon was cut at the time of the procedure. The patient has initiated occupational therapy with progressive active range of motion. She has requested reattachment of the FDS tendon. However, the medical necessity of additional surgery has not been established. This request would tend to result in surgical treatment without reasonable substantiation for same, and would likely result in increased pain and stiffness due to adhesions. Therefore, the requested procedure is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Medical Necessity
Decision: Overturned

The parent of a nineteen-year-old female enrollee has requested an Easy Standing Frame for the treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that this patient has significant lower extremity spasticity, and the requested equipment should help in that regard. Respiration, bowel function and bladder function have been shown to improve with maintaining an upright position, and this patient noted improvement in respiratory status and bowel function with prior use of the Easy Standing Frame. She is less likely to develop muscle contractions with less sitting. There is also a concern that the patient could develop a decubitus ulcer with prolonged sitting. As discussed in the references, the medical effects of standing, including as a result of the use of a standing device, are numerous and act to prevent several complications of the severity of the patient's disability. The inherent spasticity is reduced by standing, as discussed in the reference citations by Tremblay and colleagues and Dunn and colleagues. Further, as discussed by Henderson and colleagues, non-weight bearing patients are at high risk for osteoporosis due to immobility, which can be partially offset by consistent maneuvers to promote weight bearing, such as with the requested equipment. Finally, multiple other associated complications, such as urinary retention and urinary tract infections, constipation, and skin infections, can be prevented, at least in part, with the use of standing devices as indicated by Dunn and colleagues.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 5-year-old male enrollee has requested Concerta for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).   Findings:  The physician reviewer found the scientific literature does not support the medical necessity of Concerta. A 2004 article by Kratochuil and colleagues found that the use of psychostimulants in the patients age group controversial. Debate over the appropriateness of psychostimulants in this age group has continued until the present; the National Institute of Mental Health Preschool ADHD Treatment Study failed to provide adequate support for methylphenidate utilization in preschoolers due to the fact that although the drug was moderately effective, the study size was small and precluded drawing conclusions (Ghuman, et al.). A meta-analysis performed by Charach and colleagues cites one quality study specifically involving methylphenidate. However, due to its small study size, the strength of evidence was low and side effect potential was significant. All told, the scientific literature does not provide adequate support for the utilization of Concerta by this patient. As such, the medical necessity of Concerta has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old male who has been diagnosed with atrial fibrillation, paroxysmal ventricular fibrillation, and heart attack. The patient has requested authorization for a referral to a cardiologist for follow-up care and monitoring of his pacemaker. The Health Plan indicates the patients condition can be monitored by his primary care physician with referral to a cardiologist as needed.Standard of care for patients such as this is to have periodic pacemaker checks performed by a cardiologist as recommended by the pacemakers manufacturer and as needed. In this case, it is medically appropriate for the patient to be evaluated by a cardiologist on a periodic basis for the performance of pacemaker checks and for monitoring the patients ongoing cardiac risk factors. Such evaluations are medically indicated and should occur at the frequency recommended by the manufacturer of the patients pacemaker. Therefore, I have determined that the requested referral is medically necessary for the patients pacemaker monitoring. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of both legs for treatment of the enrollees leg swelling and not reconstructive in nature.  Findings:  The physician reviewer found that consistent with lipedema of the lower extremities without evidence of lymphedema. The patient has undergone extensive conservative management, including compression wrapping, physical therapy, successful weight loss and extremity massage. Her lipedema has been noted to have adversely affected her function with chronic pain and difficulty with ambulation. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lipedema. As noted by Rudkin and colleagues, lipedema is distinct from lymphedema. Schmeller and colleagues concluded that tumescent liposuction is a highly effective treatment for lipoedema with good morphological and functional long-term results. As this patient has a well-recognized condition of lipedema significantly affecting her function, and has failed treatment with reasonable conservative measures, the requested liposuction of both legs is medically necessary. In addition, the records indicate that the patient has an abnormal condition. This abnormal condition is causing the patient functional impairment. The abnormal condition is secondary to weight loss, which is a treatment for obesity, which is considered a disease. The patients functional impairment is likely to improve with the requested procedure. All told, the requested bilateral lower extremity liposuction is supported as medically necessary and reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested AmniSure testing for evaluation of her pregnancy.  Findings:  Three physician reviewers found that per the records, this patient presented with irregular contractions and uncertainty as to any loss of fluid from her vagina. An AmniSure test was done to determine whether there was any leakage of amniotic fluid.  Based on the submitted documentation, there was no speculum examination done, and no ultrasound performed. Laboratory tests may be used to confirm the clinical diagnosis when there is uncertainty.  In this patients case, there is nothing in the record to suggest that there was clinical confusion as to the presence or absence of ruptured membranes by physical examination, nitrazine testing, or ferning. It does not appear that a speculum examination was performed, nor any ferning or nitrazine testing.  The routine use of AmniSure to diagnose ruptured membranes is not recommended. Final Result: The reviewers determined that the services at issue were 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: Reviewer 1, 2, and 3 are board certified in obstetrics and gynecology and is 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.