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

The parent of a five-year-old male enrollee has requested social cognitive speech therapy and sensory integration occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the World Health Organizations International Classification of Functioning, Disability and Health (ICF) considers occupational and speech therapies to have medical value in patients who qualify based on ICFs definition of health, function and disability. While school therapies will often focus on socialization, communication, social interaction, and pragmatics, there are many aspects of pragmatic, expressive and receptive language that will not be taught by the school programs. These include safety issues in the home, dressing skills and activities of daily living (ADL), social interactions with siblings, and home skills including following parental direction, parent education and treatment of sensory issues related to the home and community. Treatment of these issues involves both social cognitive speech therapy and sensory integration occupational therapy, as these issues are often intertwined. These problems include a behavioral component and directly affect the patients function outside the school setting. In this case, the out-of-network speech therapy evaluation documented the patients speech issues. The evaluation indicates that the patients primary deficits involve auditory learning and processing language. Based on the patients deficits as documented in the out-of-network speech therapy evaluation, social cognitive speech therapy services are medically appropriate and necessary for this patient. The patients speech and language deficiencies affect his functional capacity across multiple settings (i.e., home, school and community) and as noted above, school-based therapy will not address all aspects of the patients pragmatic, expressive and receptive language delays. Concerning the request for sensory integration occupational therapy, the occupational therapy evaluations provided are insufficient in that no standardized testing was performed and activities of daily living were not adequately evaluated or documented. Neither the in-network nor the out-of-network evaluation includes a thorough evaluation of the patients sensory issues. As such, this patient requires further assessment utilizing standardized testing for both sensory integration and activities of daily living in order to determine the medical necessity of occupational therapy services utilizing sensory integration techniques. Accordingly, this patient should undergo a full occupational therapy evaluation to determine whether he has any current needs that require the services of a skilled occupational therapist.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old male enrollee has requested Glaukos Trabecular Stents for treatment of his glaucoma and cataracts. Findings:  Three physician reviewers found that the Glaukos device is U.S. Food and Drug Administration (FDA) approved and widely used as an adjunct to cataract surgery for the control of intraocular pressure in early, mild to moderate glaucoma. The studies support its efficacy, reducing or eliminating the need for eye drops for pressure control. Alternative medications, laser, or other surgical procedures for lowering pressure in lieu of the stent may be appropriate in many patients. However, this procedure is low risk with good efficacy, and has been shown to provide long-term benefits in well selected patients. Overall, this procedure is effective and was likely to have been more beneficial for treatment of this patients medical condition than any available standard treatment modality.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued substance use disorder intensive outpatient program treatment and prospective authorization and coverage for admission to a substance use disorder transitional intensive outpatient program, three days a week, four hours per day for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this patients case.  This patient had a low risk of harm as she denied any suicidal thoughts or plans, although she would occasionally have transient suicidal thoughts.  She did not have any prior suicide attempts.  The patient had a significant comorbidity of her ongoing substance use despite negative consequences.  The records noted that she has a supportive mother.  The patient is motivated for change and has been attending and participating in treatment.  She has a positive attitude toward recovery and treatment.  Based on the submitted documentation, the patient could be treated in a lower level of care.  In this patients case, treatment in an outpatient setting through a community 12-step program with the help of a sponsor is medically appropriate.  All told, continued substance use disorder intensive outpatient program treatment and admission to a substance use disorder transitional intensive outpatient program, three days a week, four hours per day were not and are not medically indicated for the treatment of this patient. 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 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

A 20-year-old female enrollee has requested mastopexy of the left breast and reduction of the right breast for treatment of her breast asymmetry. Findings:  The physician reviewer found that the patients application notes a diagnosis of Polands syndrome. Polands syndrome is a more severe defect that involves absent breast tissue including the nipple, possibly absent pectoralis major muscle and, in more severe cases, anomalies of the arm. The submitted documentation does not support a diagnosis of Polands syndrome. In addition, although the documentation provided shows a smaller left breast, it does not support an abnormal structure of the body in the patient caused by infection, trauma, tumor, congenital defect, developmental abnormality or disease. The breast tissue deficit and asymmetry is not so great so as to be considered abnormal. Thus, the California statute regarding reconstructive surgery does not apply. Furthermore, the submitted clinical evidence does not demonstrate that the patients breast asymmetry and ptosis result in a functional impairment such as pain or skin problems. In the absence of evidence of a functional deficit, the medical necessity of the proposed surgery is not established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services provided from date of dispute  forward and another psychiatric evaluation while in treatment. Findings:  The physician reviewer found that the records provided for review document that this patient showed no post-acute withdrawal symptoms. She was not a danger to herself or others, she was not gravely disabled, and she was medically stable. Her bipolar symptoms were not controlled. However, the patient was not medicated except for Seroquel and she was refusing other medications. She was insightful and aware of her addiction problems, and demonstrated motivation to remain sober via her active engagement in the recovery process. Overall, this patient did not require IOP level of care, rather, she could have been safely and effectively managed at the outpatient level of care. Given the recidivistic nature of her condition with multiple relapses and subsequent treatments, she already had a groundwork of relapse prevention education. There is no evidence to suggest that additional IOP treatment would have provided further benefit. Although the patient needed a psychiatric evaluation, this can be conducted on an outpatient basis and did not require provision in the IOP setting. As such, IOP services provided from date of dispute forward and another psychiatric evaluation while in treatment were not and are not medically necessary for treatment of this 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 psychiatry with sub-specialty certification in addiction 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 53-year-old female enrollee has requested Avastin for treatment of her stage III peritoneal carcinoma.  Findings:  Two physician reviewers found that use of Avastin maintenance therapy for surgically treated ovarian cancer, including primary peritoneal carcinoma, has been evaluated in two large clinical trials. The progression free survival was superior with addition of Avastin but the data on overall survival is not yet available. Thus, Avastin has been shown to improve progression free survival, but not overall survival in patients with ovarian cancer. The National Comprehensive Cancer Network (NCCN) indicates that eligible patients should be enrolled in clinical trials of Avastin, but does not currently recommend its use as a standard of care. Moreover, the use of Avastin is not included under the FDA approved uses of the drug. All told, the addition of Avastin to this patients treatment regimen is not likely to provide her with superior results when compared with standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for captains chair seating. The records indicate that the patient has multiple areas of pain. He is obese and has difficulties with longer distance mobility. There are, however, no indications of pertinent neurological deficits. Strength has been rated as 4+ in the limbs. He is able to ambulate within his home, as would be generally recommended in order to maximize physical activity in the setting of his health conditions. The patient uses a power scooter for his longer distance mobility in the community. The records do not establish that the patient has impairments that require specialized seating instead of a standard seating system on his power scooter. Therefore, the requested captains chair seating is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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

Nature of Statutory Criteria/ Case Summary:  According to the records, the enrollee went to the urgent care center complaining of psoriasis all over her body with the exception of her face, neck, and chest .  She reported the sites had not improved, had flared and were itchy.  It was noted her whole upper body had healed well and she had been applying betamethasone and calcipotriene to her legs.  However, her legs were starting to become itchy and the physician noted scattered, small, psoriatic, annular, clustered plaques to her shins. This was a new flare due to stopping Otezla.  It was recommended she continue utilizing Otezla and follow-up. According to a review of the record, there are effective, safe alternatives that have not been trialed. The health plan indicates Otezla is medically necessary if the enrollee has attempted therapy with preferred alternative drugs for the treatment of psoriasis (methotrexate, cyclosporine, or acitretin and then two of the following drugs: Cosentyx, Enbrel, or Humira). The enrollee has a history of plaque psoriasis. She has tried betamethasone and calcipotriene with minimal benefit. She has a history of psoriatic arthropathy with pain in her achilles and lateral foot. The enrollee has a contraindication to acitretin. However, the enrollee has no documented contraindications to the use of cyclosporine, Cosentyx, Enbrel or Humira. Current peer reviewed literature supports the use of the preferred medication to Otezla. study's found biologics are highly effective treatments for moderate-severe psoriasis with a high percentage of patients achieving 75% improvement in Psoriasis. However, psoriasis is a chronic disease and long-term efficacy is critical. When comparing medications at one year, response rates among the initial treatment groups were best with secukinumab (Cosentyx) and worst with apremilast (Otezla). In initial responders who received one year of continuous treatment, maintenance was best with adalimumab (Humira) and worst with apremilast (Otezla).There has been robust clinical data demonstrating the efficacy of the preferred alternative, Humira (adalimumab). Adalimumab efficacy was well maintained over more than three years of continuous therapy for patients with sustained initial Psoriasis Area and Severity Index.   Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Dermatology 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 similar medical condition.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing services, which include physical therapy, occupational therapy, and speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients hemorrhagic stroke. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records did not indicate that SNF services were medically necessary to safely and effectively provide reasonable treatment for this patient. On 7/01/18, the patient did not require complex wound care, enteral feeds, tracheostomy care, or other skilled nursing services. This patient did not require skilled therapy services with a specialized skill, knowledge, and judgment of a qualified therapist at a SNF level of care. The patient may benefit from additional physical therapy, occupational therapy, and speech therapy; however, the documentation does not support that the patient requires inpatient level of care in a SNF on a daily basis. Therefore, the requested skilled nursing services (SNF) at South Coast Post-Acute, which include physical therapy, occupational therapy, and speech therapy are 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.There is sufficient support in the documentation provided for the medical necessity of the services at issue in this clinical setting. The patient remained symptomatic.   His mood was often described as irritable and anxious.  He was documented as being intrusive to peers, impulsive, and having lack of motivation. He was noted to minimize his relapses and probation and was detained at a juvenile detention facility.  The American Society of Addiction Medication (ASAM) Criteria, a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive but safe treatment setting.  ASAM also advises that the length of service should be determined by the patients progress with his treatment plan as determined by the patient and treatment providers. Based on current medical literature, ASAM criteria, and the patients documented clinical history, the patients admission to the IOP level of care from was and is medically necessary for treatment of this patient.  Findings:The reviewer has determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of chronic headaches.Findings:  Botox, a brand name for botulinum toxin, has been U.S. Food and Drug Administration approved for the treatment of migraine headache in adults. However, the medical literature indicates that Botox has been used off label for a number of years for treatment of those who are diagnosed with chronic migraine headaches and is consistent with the standard of care for those who manage such patients. The medical evidence has shown Botox as a safe and effective treatment option in patients for whom standard therapies have failed. The provider noted that this patient has failed treatment with parenteral Depakote, parenteral ergotamine, parenteral Toradol, Phenergan, Zofran, oral triptans, topiramate, and amitriptyline. This patient, with intractable chronic migraine and tension like headache, now rendered non-functional due to headache pain, has tried and failed a majority of standard as well as some non-standard treatment modalities. Accordingly, in this patients case, Botox has been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has determined that 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 pediatrics with expertise in pediatric 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: Overturned

A 55-year-old male enrollee has requested for Oncotype DX Gene Expressing Profiling Assay (Oncotype DX Assay) for evaluation of his breast cancer. Findings:  Two physician reviewers found that the Oncotype DX Assay is multi-gene profile of an individuals breast cancer cells. It provides unique biologic information that predicts the risk of breast cancer recurrence within 10 years if chemotherapy is not used. Furthermore, it provides data as to whether chemotherapy is likely to be of benefit. The use of the Oncotype DX Assay has become standard of care in appropriate situations (female patients with estrogen receptor positive, node negative and HER2 negative breast cancer). For female patients, its use is within National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines. There is far less data in relation to male patients with breast cancer. A study by Shak demonstrated that males had a similar distribution of the genes within the assay as females. Generally speaking, male breast cancer is treated by the same guidelines as is female breast cancer. In view of its relative rarity, a study large enough to prove the validity of the Oncotype DX Assay in male patients is not likely to occur. However, the oncology community has accepted the validity of Oncotype DX analysis in this population. All told, there is adequate evidence demonstrating that the Oncotype DX Assay is likely to be of clinical benefit in men with breast cancer.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested Suboxone for 1 year for treatment of his opiate dependency.  Findings:  The physician reviewer found that based on review of the available records, this patient has a severe addiction and co-morbid pain problem. Given his previous relapses with attempts to taper off Suboxone, this therapy remains the most prudent and safe medical treatment intervention for his medical problems. With Suboxone, the patient has the advantage of partial opioid agonist for his pain and the partial antagonist action for prevention of opioid use. His provider clearly supports this monitored use of Suboxone and reports that it has helped the patients pain and addiction issues. For these reasons, the requested one year of Suboxone therapy has been established as medically necessary in this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested  L4-5 disc replacement arthroplasty for treatment of his severe back pain.  Findings:  Three physician reviewers found that the medical records indicate that this patient has multiple levels of lumbar disc degeneration on MRI scans. Artificial lumbar disc replacement is only U.S. Food and Drug Administration (FDA) approved for single-level disc degeneration. Multiple levels are a contraindication at this time. More outcomes data is needed to support the safety and efficacy of this procedure when there are multiple levels of lumbar degeneration. Given the lack of peer-reviewed medical literature demonstrating the clinical efficacy of the requested L4-5 disc replacement arthroplasty, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.