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

A 25-year-old female enrollee has requested psychotherapy twice a week with a PhD psychologist, monthly psychiatric appointment with Comprehensive Neurobehavioral Specialists (CNS) and applied behavioral analysis (ABA) therapy for treatment of her mental health conditions. Findings:  The physician reviewer found that applied behavior analysis (ABA) is an empirically proven treatment intervention for children, adolescents and adults afflicted with autistic spectrum disorders.  However, the documentation provided does not substantiate a diagnosis of Aspergers disorder.  Determination of this condition involves input from multiple disciplines and structured interviews. It is uncommon practice to make this diagnosis after a single visit and the evaluating physician acknowledged no past history of the diagnosis and conceded that it is difficult to tease apart which of her symptoms are from Aspergers versus ADHD versus sleep disorder versus depression.  Diagnostic uncertainty aside, there was no conclusive, well-delineated functionally impairing symptomatologies from Aspergers disorder that would support targeted treatment goals of ABA. ABA therapy is not medically necessary for treatment of the patients medical condition.  Psychotherapy and monthly medication management with a psychiatrist as part of a multi-dimensional and comprehensive evidence-based treatment plan are appropriate, safe and consistent with good medical practice in the United States.  Thus, psychotherapy twice a week with a PhD psychologist and monthly psychiatric appointments are medically necessary for treatment of the enrollees medical condition at this time.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an eleven-month-old female enrollee who is status-post double barrel colostomy with a low imperforate anus (IA) and a possible 2mm Fourchette fistula along with a surgically released tethered spinal cord are requesting coverage for a posterior sagittal anorectoplasty ((PSARP) with an interdisciplinary surgical team approach consisting of a pediatric surgeon, pediatric gynecologist and a pediatric urologist who are experienced in providing a PSARP.  Findings:  The physician reviewer found that Leavitt and colleagues provide the rationale for why a pediatric surgeon alone with experience in correcting anorectal malformations is sufficient for the vast majority of these cases. The study by Leavitt and colleagues showed that in young female patients (girls) with rectovestibular fistulae, only 17% had associated gynecological anomalies. Of those 48 patients, only 20 or 7% of the entire patient total required a repair that required the services of a pediatric gynecologist. Thus, 93% of the time, a pediatric surgeon alone would be all that is required to perform the appropriate operation. The study by Javid and colleagues involved a large series of girls with rectovestibular fistulae and confirmed that comparable outcomes can be achieved with surgical teams without the presence of a pediatric gynecologist compared to outcomes achieved by surgical teams with a pediatric gynecologist. There are no studies published that demonstrate superior outcomes in these types of surgeries with the involvement of a pediatric gynecologist.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for autonomic nervous function testing. In autonomic nervous system dysfunction, patients may present with a myriad of symptoms including orthostatic intolerance, labile blood pressure, disorders of sweating and thermoregulation, neurogenic bladder, and gastrointestinal dysmotility. Although autonomic symptoms may be among the most debilitating features of many progressive conditions, they are often treatable. Given the complexity of the autonomic system there is no single test that precisely reflects the function of a specific branch of this system. Autonomic testing is grouped into general categories of autonomic activity including cardiovagal tests, adrenergic tests, and sudomotor tests. Therefore, it is common to order perform several tests based on diverse autonomic reflexes. According to the American Academy of Neurology, autonomic function tests are safe and have an extremely high value-to-risk ratio. In this case, the patient has symptoms suggestive of autonomic nervous system dysfunction with complaints of gastrointestinal pain and dysmotility, thermoregulatory, orthostasis, and paresthesias. Based on the current medical literature, autonomic testing is safe, non-invasive and required for accurate diagnosis of underlying autonomic system dysfunction and subsequent treatment of debilitating autonomic symptoms. Therefore, the requested autonomic nervous function testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for platelet rich plasma (PRP) injection (0232T). This patient presents with elbow epicondylitis that has been treated with Naproxen and diclofenac gel, cortisone injection with some relief for three months, and physical therapy with short-term benefit. The patients provider has recommended treatment with PRP injections. However, the results of numerous quality trials on the efficacy of PRP for treatment of chronic lateral epicondylitis have yielded variable results. A review of current literature by Kwapisz and colleagues, and a meta-analysis of Level 1 evidence by Chen and colleagues, concluded that more studies on larger cohorts, with comparable formulations, and longer follow-up are required to determine whether PRP injections are an effective treatment modality in patients with elbow pathologies. Linnanmaki and colleagues found that PRP injections did not improve pain or function at one year of follow-up in patients with lateral epicondylitis compared with those who were given a saline injection. All told, the requested PRP injection (0232T) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested PRP injection (0232T) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee has requested magnetic resonance imaging (MRI) of the right breast for evaluation of her medical condition.   Findings:  Two physician reviewers found that the requested diagnostic procedure is not likely to be more beneficial than other available standard methods of evaluating this patients medical condition. When used for evaluation of a palpable breast mass with negative traditional imaging, breast MRI offers low yield of cancer diagnosis and low specificity. Moreover, a biopsy is indicated for palpable masses. Although, the patient does not have a palpable finding, her findings on mammogram are similar, and a biopsy should first be performed. In this case, there is no indication a biopsy has been attempted or cannot be attempted. Further, an MRI should not be a substitute for biopsy. Thus, the request for an MRI of the right breast is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: As reported in the current medical literature, ABA is a medically necessary treatment for patients with autism based on the evidence demonstrating its effectiveness. Findings:  The physician reviewer found that the National Autism Center National Standards Project identified ABA as the most effective, evidence-based treatment available to treat patients with autism spectrum disorders. To determine whether a specific number of ABA hours are medically necessary, the Behavior Analyst Certification Board (BACB) has established guidelines which highlight that treatment dosage is dependent upon goals of treatment, specific client needs, and response to treatment. A study evaluated the dosage of ABA and treatment outcomes of hundreds of children. The authors reported that regression analysis revealed a strong dosage to outcome relationship with children receiving a higher dosage of ABA meeting more treatment goals. While this patient has demonstrated progress, the rate of combined target behaviors is still occurring several times an hour. Of specific concern is the patients elopement, as this behavior poses a safety concern, and was reported to occur multiple times per hour during the previous authorization period. Further, the provider listed several goals that include skill acquisition and behavior reduction, yet require additional time each week to address. The inclusion of the additional five hours of ABA services per week, for a total of 40 hours, is supported by the medical literature. Based on the needs of the patient, the requested 40 hours per week of direct one-on-one ABA therapy are medically necessary.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 psychologist and is a board certified behavior analyst and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested shockwave therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Shockwave therapy was not and is not medically necessary for treatment of the patients medical condition. Extracorporeal shockwave therapy (ESWT) is among the accepted treatments for pain from calcifying tendinitis of the shoulder and has been suggested to be an effective treatment option before surgery, but only after failure of conservative treatments. The available noninvasive treatments include physical therapy, iontophoresis, deep friction massage, local application of non-inflammatory drugs, and oral non-steroidal anti-inflammatory medications. Needle irrigationaspiration of calcium deposits and a subacromial bursal steroid injection can also be considered. For this reason, shockwave therapy has not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and 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: Upheld

A 63-year-old male enrollee has requested coverage for acute physical therapy and occupational therapy for treatment of his diabetic ketoacidosis status post fall.  Findings:  The physician reviewer found that the patients rehabilitative needs are not complex as he requires routine nursing care, basic therapy interventions, basic reconditioning exercise, instruction for self-care, and family training. Lower limb strengthening exercises would be appropriate given his diabetic polyneuropathy. The patient would also benefit from higher levels of physical activity in the long-term.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for high intensity focused ultrasound (HIFU) for treatment of the enrollees desmoid fibromatosis of the right breast and chest wall. Findings: Two physician reviewers found that the request for HIFU is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Wang and colleagues evaluated the feasibility, safety and therapeutic effects of HIFU in the treatment of extra-abdominal desmoid tumors. The authors concluded that HIFU could be used as an effective minimally invasive therapy for local control of extra-abdominal desmoid tumors. The patient presents with right breast desmoid fibromatosis extending into the chest wall and intercostal space. Surgery is not indicated due to the size and location of the right chest wall mass and a significant recurrence rate. In addition, treatment with radiation is likely to damage the lungs and the tumor invaded ribs and also preclude any type of possible resection in the future. The patient has failed chemotherapy twice with significant side effects. Thus, HIFU is a medically reasonable and appropriate in this clinical setting. Accordingly, the request for HIFU has been established as 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 service is 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 physician reviewers are board certified in interventional radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year old male enrollee requested authorization and coverage of external counterpulsation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees congestive heart failure.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 15-year-old female who has a strong history of a significant axis II disorder with manipulative behaviors. She was admitted to residential treatment on 5/17/04 following partial hospitalization services. The patient was on 24-hour observation until 7/8/04. The Health Plan indicates that as of 7/6/04 the patient was appropriate for discharge to a less intense level of care. A request has been made for coverage for residential treatment center services from 7/6/04 to present.The Health Plans denial should be upheld. The submitted evidence does not demonstrate the patient required continued residential treatment for psychiatric and/or medical issues after 7/6/04. As of 7/6/04, the patient was medically stable and could have been appropriately treated with partial hospitalization and possible intensive outpatient psychotherapy. Based upon the clinical records provided, there was no medical indication for residential treatment services beyond 7/6/04. Therefore, I have determined that the services at issue were not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female who had bilateral mammograms and breast sonograms in April 2005. Bilateral simple cysts were present with probable benign small complex cysts seen in both breasts. A six-month follow-up exam was suggested. MRI of the breasts was performed in June 2005, which showed two small masses on the right and one on the left and ultrasound-guided biopsies were suggested. In July 2005 biopsies of nodules in the right breast at 9 oclock and 12 oclock were performed, which showed adenosis and focal apocrine metaplasia. Follow-up MRI and ultrasound of both breasts was recommended in six months. A bilateral breast ultrasound in October 2005 showed no suspicious nodules with the previous complex cysts either stable or resolved. Bilateral mammograms and breasts sonograms were obtained in April 2006 showing a new complex cyst at 3 oclock, which was aspirated under ultrasound guidance in May 2006. Cytology findings were benign. The patient has a family history of breast cancer is an aunt diagnosed at age 45.A breast MRI has been recommended for further follow-up. The Health Plan has denied coverage for the requested MRI on the basis that it is not medically necessary in this clinical setting.There are several indications for MRI of the breast including pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. High risk patients are those with a personal history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar, and prior mantle radiation.This patient has no indication for an MRI of the breast. The several biopsies performed showed no cancer or atypia. Her family history of an aunt with breast cancer is inadequate evidence of a genetic predisposition. Continued follow-up mammograms and ultrasounds are appropriate in this setting. The requested breast MRI is not medically indicated at this time.Based upon the information set forth above, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the prescription drug Ajovy. The U.S. Food and Drug Administration (FDA) approves the use of Ajovy, a calcitonin gene-related peptide (CGRP) antagonist, for the preventive treatment of migraines in adults. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inability to tolerate a tricyclic antidepressant such as amitriptyline and a serotoninnorepinephrine reuptake inhibitor such as duloxetine. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits, such as a reduction in mean monthly headache days, can be documented. In this case, the patient has a history of chronic migraines that has not responded to multiple preventative medications including duloxetine and amitriptyline. The records note that Ajovy has been effective in decreasing the frequency of the patients migraines. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, the prescription drug Ajovy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 neurology 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 64-year-old male enrollee has requested for services provided which included high-frequency pulsed electromagnetic stimulation for treatment of his neck pain and numbness and the services rendered were not required on an urgent basis.  Findings:  Three physician reviewers found that High-frequency electromagnetic stimulation was not likely to be more beneficial for this patient than any other available standard therapy. According to the Cochrane Database of Systematic Reviews, the authors were unable to make any definite statements on the efficacy and clinical usefulness of electrotherapy modalities for neck pain.  The quality of evidence is considered low. The Quebec Task Force Guidelines for the Management of Whiplash-Associated Disorders indicates treatment for patients with whiplash-associated disorders grade 1-3 should include manipulation, mobilizations, range of motion exercises, non-narcotic analgesia, and non-steroidal anti-inflammatory drugs. High-frequency pulsed electromagnetic stimulation is not included in these guidelines. All told, available scientific data does not support the use of high-frequency pulsed electromagnetic stimulation in this setting. The submitted documentation indicates the patients accident took place in San Diego, California. He then travelled to the Philippines for business purposes. There is no evidence of a thorough and detailed evaluation and workup supporting a diagnosis of whiplash and no indication of the grade/severity of the patients injuries. The evidence does not support the presence of an injury that would cause a reasonable and prudent layperson to seek treatment while out of his Plans service area.