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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intravenous immune globulin (IVIG) therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient was diagnosed with anxiety and depression and non-epileptic convulsions during a hospital stay. He was prescribed pharmacotherapy for anxiety and depression along with outpatient psychiatric treatment. He had a normal MRI of the brain that was not consistent with encephalitis, and his EEG showed no evidence of epileptiform activity. A diagnosis of autoimmune encephalitis was made by a treating provider, but it is not clear on the basis of what criteria this diagnosis was made. The records do not document abnormal autoimmune markers. Furthermore, his brain imaging, EEG and physical examination were not suggestive of encephalitis. While it was reported that the patient received IVIG and experienced temporary improvement in abnormal movements, it was not clear that this was as a direct result of the IVIG nor was it a sustained effect. IVIG is not a benign therapy and has potentially significant side effects, including anaphylaxis, renal failure, fever, headache, muscle cramps, and pain. The medical evidence does not support the requested services in this clinical setting. Therefore, IVIG is not medically necessary 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 reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested the use of a continuous passive motion (CPM) device for the treatment of her condition. Findings:  Two physician reviewers found that the evidence-based literature does not suggest that in standard shoulder surgery, including acromioplasty, distal clavicle resection and rotator cuff repair, use of a CPM device is more beneficial than traditional therapy, including early range of motion and early home exercises. Of note, this individual did not begin using the CPM within 72 hours and used it well beyond the traditional time frame where this is considered to be of value.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female with severe open bite deformity secondary to maxillary hypoplasia and mandibular hypoplasia. She also has lip incompetence secondary to microgenia. There is also documentation of temporomandibular joint arthralgia. X-rays confirm the severity of the facial skeletal deformity and the dysfunctional dental malocclusion. The patients provider has recommended the patient undergo Lefort I osteotomy, bilateral sagittal split ramus osteotomy, and an osteotomy of the inferior border of the mandible. The Health Plan has denied authorization for oral surgery on the basis that it is not medically necessary.The submitted x-rays reveal an obvious open bite deformity. The patients dental occlusion is completely dysfunctional. This problem is a skeletal developmental deformity and cannot be managed without orthognathic surgery. The patient has been diagnosed with temporomandibular arthralgia, which is quite common with this deformity. The discomfort and dental occlusal dysfunction secondary to skeletal deformity are medical problems and confirm the medical necessity for treatment. Therefore, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a six-year-old male enrollee has requested authorization and coverage for individual and group speech therapy for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that the request for individual and group speech therapy is not medically necessary for this patient. According to colleagues there is some evidence that social skills groups can improve social competence for some children and adolescents with ASD although the study underscores that more research is needed to draw more robust conclusions, especially with respect to improvements in quality of life. Another systematic review on the subject indicates that Social skills interventions presently appear modestly effective for youth with ASD, but may not generalize to school settings or self-reported social behavior. In sum, the data on the efficacy of social skills groups in autism appears to be emerging. In this case, the patient has demonstrated significant improvement in speech therapy in the areas of expressive communication skills. The majority of the patients delays in communication skills are likely due to behaviors associated with ASD, and these are best addressed in the context of ABA. For the reasons provided, the requested services are not medically necessary for 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 57-year-old female with rheumatoid arthritis. She has significant ankle and subtalar involvement. The patients surgeon recommended subtalar fusion and total ankle arthroplasty. The patients surgeon is no longer with the patients medical group and is unable to perform the surgery as proposed. The patient is requesting a referral to have the proposed surgery performed by an out-of-network surgeon. The patient has a complex disease and has had multiple joint replacements including knees, shoulders, and hips. She has been referred to an in-network surgeon for a consultation. The in-network surgeon is an orthopedic foot and ankle specialist. There is no evidence that the patient requires the services of the out-of-network surgeon. Though the patient prefers to be treated by the out-of-network surgeon, there is no evidence that the in-network surgeon is unable to provide medically appropriate care. Therefore, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested weekly psychotherapy for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  In a letter, the provider noted that the patient had achieved remission of her major depressive episode.  There was no mention of severe affective symptomatologies or suicidality.  Based on the letter, it appears that the desired observable outcomes of decreasing anxiety and improving mood and functionality had been achieved.  Thus, at this point, weekly services were no longer medically necessary.  Elements commonly seen in mental health documentation, such as patient goals, chief complaint, mental status examination, sequential objective rating scales, physical examination, assessment, interpretative summary or plan, were not provided.  In sum, weekly psychotherapy was initially medically necessary for the treatment of this patient.  However, the submitted documentation fails to demonstrate the medical necessity of continued weekly psychotherapy.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested Dexilant for treatment of her gastroesophageal reflux disease.  Findings:  The physician reviewer found the submitted medical records fail to demonstrate the medical necessity of the requested medication in this patients case.  This patient has upper abdominal symptoms.  The documentation indicates that she developed side effects from Nexium.  In order to approve Dexilant, there must be a trial of all of the preferred proton pump inhibitors such as Nexium, lansoprazole at single and double doses for a total of eight weeks, omeprazole single and double doses for a total of eight weeks, and pantoprazole single and double doses for a total of eight weeks. The clinical notes do not support the medical necessity of Dexilant.  All told, Dexilant is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old male enrollee has requested for a myoelectric prosthetic device for treatment of his post traumatic non-dominant right shoulder disarticulation amputation. Findings:  The physician reviewer found that it would be difficult for the patient to use a body-powered prosthetic device in large part due to a limited ability to actively retract and protract his shoulder.  The patients shoulder and scapular pathology make it difficult to actively retract and protract his shoulder. These movements are essential in proper use of a body-controlled prosthesis.
Appeal type: Medical Necessity
Decision: Overturned

A 15-year-old female enrollee requested residential treatment services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that in reviewing the clinical documentation, the patient has improved during her course of treatment.  However, she has not yet consolidated the treatment gains needed to succeed in the outpatient setting.  This patient continues to demonstrate significant symptomatologies.  The evidence-based services have been for active treatment and are being provided in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting.  The services at issue were and are expected to improve her condition and prevent a more serious episode of illness.  All told, residential treatment was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old male who has had back pain since June 2003. The patients symptoms improved 40% following a lumbar injection in January 2005. His pain improved 90% post second lumbar facet injection in March 2005, but has returned. The patients provider would now like to perform radiofrequency treatment of the patients lumbar facets in order to achieve more lasting pain relief. The Health Plan has denied coverage for radiofrequency treatment indicating the requested therapy is not medically necessary for treatment of the patients condition.Review of the submitted records indicates the patient has tried conservative therapies without sustained benefit. The submitted information includes a study showing statistical improvement post radiofrequency ablation as compared to a sham study. Given that the patient has not been able to obtain lasting relief from other treatment modalities, radiofrequency treatment is medically reasonable and appropriate. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Norditropin Flexpro 15 mg/1.5 mL. Findings:  The physician reviewer found that manifestations of Down syndrome include short stature. However, short stature in the context of Down syndrome is not likely due to growth hormone (GH) deficiency. Common contributors to poor growth in patients with Down syndrome include cyanotic heart disease and trisomy 21. This patient is GH sufficient based on his normal growth pattern compared to his peers with Down syndrome, his circulating insulin like growth factor 1 (IGF-1) and insulin like growth factor binding protein 3 (IGFBP-3) levels, as well as his normal bone age, and normal responses to standard GH provocative tests. Magnetic resonance imaging (MRI) of the brain with and without gadolinium contrast to exclude intracranial pathology is important prior to administration of GH therapy. The report for this patients MRI of the brain was not provided for review. In addition, the patients afternoon cortisol level was slightly elevated in 2018, but there is no report that a 24-hour urinary free cortisol assessment to exclude hypercortisolism has been performed. Based on the available documentation, this patient does not meet the accepted and U.S. Food and Drug Administration (FDA) approved indication for Norditropin. Therefore, the requested Norditropin Flexpro 15 mg/1.5 mL is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested balloon sinus ostial dilation for treatment of his chronic sinusitis.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the use of balloon ostial dilation in this clinical setting. The requested procedure is a recognized surgical technique designed to improve ventilation and drainage of chronically inflamed and/or infected paranasal sinuses. In this case, the patient has chronic symptoms of post nasal drainage and frontal headaches. The patient has a septal deviation and two small maxillary antral cysts, however there are no objective findings of anatomic abnormality or obstruction and no history of recurrent sinus infections. It is not likely that surgical intervention will resolve symptoms of post nasal drainage. In addition, there is no evidence that the proposed procedure would resolve frontal headaches often associated with exercise. As such, the requested procedure is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for residential treatment services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient had no recent intensive outpatient treatment for her alcoholism and no failed outpatient treatment for her childhood history of trauma. Further, the records indicate that she was not suicidal and was taking care of her daily living skills. Her mental status examination (MSE) was relatively normal and she had no acute medical problems. Applying the American Society of Addiction Medicine (ASAM) and American Psychiatric Association (APA) guidelines, patients with these low degree symptoms can be safely and effectively treated  on an outpatient basis.  All told, the residential treatment services have not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested a computed tomography (CT) scan of the chest (codes 71250/71260) for evaluation of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the diagnostic study at issue. The documentation submitted for review indicates that the patient has a history of an ovarian cyst and progressing abdominal pain. According to National Imaging Associates (NIA) clinical guideline criteria, a chest CT is medically  necessary for the evaluation of conditions such as known cancer, suspicious mass on chest x-ray, interstitial lung disease or infection after prior chest x-ray, vascular disease, pulmonary embolism with proper clinical suspicion, and trauma. Based on the medical records submitted for review, the patient does not have any of the conditions to establish the medical necessity for the chest CT scan performed. As such, the diagnostic study at issue was not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for total abdominal hysterectomy. The American College of Obstetricians and Gynecologists (ACOG) recommends use of non-steroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, and intrauterine devices for the treatment of menorrhagia. The ACOG specifically noted that surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management. Surgical intervention can include endometrial ablation or vaginal hysterectomy or total laparoscopic hysterectomy with or without bilateral salpingectomy. Current medical literature indicates that minimally invasive surgery is associated with a lower complication rate for well selected patients. This patients records document prior treatment has included medroxyprogesterone. However, the documentation does not demonstrate that first-line therapies have failed to provide the patient with sufficient symptomatic improvement. The patient has not exhausted standard treatment with NSAIDs, oral contraceptives, or an intrauterine device prior to consideration for surgical intervention. Therefore, the requested total abdominal hysterectomy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 obstetrics and gynecology 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 hyperbaric oxygen chamber and oxygen concentrator for treatment of the enrollees tinnitus. Findings:  The physician reviewer found that the request for hyperbaric oxygen chamber and oxygen concentrator are not medically necessary for treatment of the patients medical condition. The medical literature does not demonstrate any longstanding clinical benefit utilizing hyperbaric oxygen therapy for the treatment of subjective tinnitus. The data reports a modest degree of improvement of symptoms of sudden hearing loss when the treatment is initiated shortly after the development of the hearing loss. In this case, the patients trauma occurred more than one year ago. In addition, colleagues state that For people with acute [idiopathic sudden sensorineural hearing loss] ISSHL, the application of [hyperbaric oxygen therapy] HBOT significantly improved hearing, but the clinical significance remains unclear. The authors further reported that the effect of HBOT could not be assessed on tinnitus by pooled analysis. The authors concluded that There is no evidence of a beneficial effect of HBOT on chronic ISSHL or tinnitus and we do not recommend the use of HBOT for this purpose. Given the lack of benefit of the use of hyperbaric oxygen therapy for the treatment of tinnitus, the requested services are not medically necessary for 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 otolaryngology 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 12-year-old male enrollee has requested physical therapy, two times per week, for treatment of the enrollee, who is status post knee surgery. Findings:  The physician reviewer found that extensive physical therapy may be necessary following anterior cruciate repair in order to achieve optimal clinical outcome. Closely supervised therapeutic exercise and neuromuscular training is critical to restoring knee joint stability and proper joint motion. There is evidence in the literature that younger patients, in particular, may require more prolonged courses of supervised therapy in order to insure adherence to their rehabilitation program.  In this patients case, the treating orthopedic surgeon has recommended that supervised therapy be continued due to the patients skeletal immaturity and the complicated nature of his surgical repair.  In the case under review, the inability of the patient to correctly perform therapeutic exercise without skilled supervision has been documented. Given his young age, complexity of the surgical repair and ongoing need for closely supervised treatment, continuation of skilled therapy was necessary.  All told, physical therapy, two times per week, was and is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male has requested speech therapy services at a frequency of two sessions per week for 30 minutes per session for treatment of his autistic disorder and speech delay.  Findings:  The physician reviewer found that this patient carries dual diagnoses of autism and a developmental delay. In addition, initial studies also suggest the possibility of hyperactivity. His prognosis for normal development, social skills, and language is limited without significant intervention. There is robust medical literature advocating speech therapy for autistic children. The above cited evidence demonstrates that speech therapy is a medically necessary intervention for patients with autism. In this case, the requested speech therapy sessions for 30 minutes twice a week are medically indicated and consistent with the standard of care.