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

The patients parent has requested authorization and coverage for safety sleep bed. Researchers noted that assessing children with autism for sleep disorders is critical as inadequate sleep can have detrimental effects on memory, attention, cognition, daytime behavior, and even language acquisition. Medical literature found that increased night time awakening and decreased willingness to fall asleep were shown to be associated with poor appetite and growth. Increased aggression, hyperactivity, and social difficulties could be indicators for poor mental health outcomes that were observed due to sleep disturbance secondary to autism. Applied behavior analysis (ABA) may be effective over time, but ABA is not an immediate solution to the patients current safety concerns. The patient has demonstrated persistent behaviors that put herself and her family at risk of injury at bedtime and throughout the night. These behaviors include kicking, hitting, biting, head banging, and trying to leave the house. The patient does not have the awareness or insight to realize the risks involved for herself or others. According to the patients parent, past attempts to contain the patient in secure bed tents were initially successful, until she grew strong enough to break through these bed tents. It is reasonable to conclude, based on the prior behavior patterns that the patient would settle down and fall asleep if contained in a secure bed for the night. This would allow the patient and her family to sleep through the night, which is essential for the patients optimal functioning and development. Given the current medical literature, the requested safety sleep bed is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 psychiatry with subspecialty 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: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested Percutaneous Tibial Nerve Stimulation (PTNS) for treatment of her nocturia.   Findings:  Three physician reviewers found that the technique of percutaneous tibial nerve stimulation (PTNS) has been evaluated in the medical studies for the treatment of overactive bladder (Peters, et al). However, there is a paucity of published literature supporting this technique as within the standard of care for patients with overactive bladder. As concluded by Civic and colleagues, further studies are needed with longer periods of observation to determine the durability of the treatment. This patient was advised to reduce fluid intake at the same time of the initiation of the PTNS but this should have been done prior to the PTNS treatment. Since PTNS is not supported as an effective treatment in overactive bladder patients, the therapy is not likely to be more beneficial than alternative therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that based on the documentation provided for this review, the patient does not have typical symptoms associated with functional impairment related to the abdominal pannus. There are no complaints of pain, chronic rashes, infections or other difficulties associated with her pannus. The submitted photographs demonstrated that she has a relatively mild excess skin. Researchers noted that the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms However, there is insufficient detail in the medical documentation to support that there are functional problems related to this patients lower abdominal overhang. Thus, panniculectomy for this patient is not supported as medically necessary. With regard to whether the requested surgery is reconstructive in nature, there is evidence of mild abnormality of the lower abdomen. This condition was the result of treatment of obesity, which is a form of disease. However, there is no evidence of functional impairment. Further, although the appearance is abnormal, panniculectomy would only provide a minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the requested surgery is not reconstructive in nature and 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 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: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested transcatheter arterial chemoembolization (TACE) for treatment of her breast cancer with liver metastases.  Findings:  The physician reviewer found that in the medical literature, TACE has been shown to decrease liver progression and overall survival rates in patients with hepatocellular carcinoma (HCC) with liver metastases from colon, neuroendocrine, and breast cancer. One study from Li and colleagues comparing the efficacy of TACE versus chemotherapy demonstrated an improved response rate for patients following treatment with TACE (37.5%) compared to only 10% with chemotherapy alone. A study by Martin and colleagues evaluated the efficacy of TACE with DEB in a subset of patients with metastatic breast cancer and reported a response rate of 58%. Given that this patients condition has progressed despite multiple rounds of chemotherapy, her cancer is considered chemoresistant. Since TACE has been shown to be safe and effective in this clinical setting, the requested therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cervical discectomy and fusion (ACDF) of C4-7. Although some of the patients symptoms are not explained by her cervical imaging findings such as dizziness, hemibody numbness, trouble walking, and leg weakness, this patient does have pain and numbness radiating from her neck into her arms and hands consistent with cervical radiculopathy. The patients cervical spine MRI explains her radiculopathy as it shows severe bilateral foraminal narrowing at C5-6 and severe left and moderate right foraminal narrowing at C6-7. The patients radicular symptoms have persisted despite several years of nonsurgical treatments. Surgery to address her radiculopathy is therefore reasonable. However, there is a lack of documentation of any foraminal narrowing or any instability at C4-5 to support surgical intervention at that level. Moreover, both of the providers who recommended surgery discussed ACDF at C5-7, and not at the C4-5 level. Given these findings, the requested ACDF from C5-7 is medically necessary for treatment of this patient, while ACDF from C4-5 is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurological 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 four-year-old female enrollee has requested  for speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for treatment of the enrollees pervasive developmental disorder. Findings:  Two physician reviewers found that ABA therapy, speech therapy and occupational therapy are medically indicated for the treatment of this patient based upon a review of the current literature.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested ongoing hormone replacement therapy (testosterone pellet) for the treatment of her condition. Findings:  Two physician reviewers found that this patient has menopausal symptoms and is not a candidate for estrogen therapy to treat her symptoms due to a previous medical condition. There is evidence that testosterone supplementation is efficacious, and it has been used to relieve menopausal symptoms and sexual dysfunction. As this patient cannot take estrogen, testosterone is medically appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that at the time of admission the patient presented with significant anger management and physical aggression issues that placed her sister at high level of risk or harm and also placed the family home at risk of destruction. The patient had already received outpatient, inpatient and PHP with no improvement. In addition, she had already failed treatment with multiple medications. Therefore, the admission to residential level of care was appropriate and medically necessary. Her recent dangerous behaviors and especially physical aggression toward her sister as well as the chronic nature of her impairments did make RTC the most reasonable level of care. Additionally, having failed prior treatments, she did require admission for a coordinated assessment with follow up to determine the cause of her problems and an appropriate treatment plan. The medical records indicate that by the date indicated, the patient reported feeling much better and was getting along better with the family and beginning to consent to meet with her sister to work on their relationship. Therefore, she could have been stepped down to PHP level of care to safely continue her treatment. As such, the residential treatment center services were medically necessary for treatment of the patients medical condition, however from the specified date and forward the services in dispute were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography scan provided on 2/07/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees concussion. A very common and widely researched issue confronted by emergency rooms nationwide is the over-utilization of CT scans for patients with relatively minor head trauma.  There are several programs available to help triage these patients. In an article written by Haydel in 2000, The authors concluded that CT was indicated in all patients with minor head injury. In subsequent prospective studies of patients with a score of 15 on the Glasgow Coma Scale, the rate of intracranial lesions on CT was much lower (6 to 9 percent). Various clinical presentations were found to warrant CT scans in the setting of minor trauma.  These include the presence of one or more of the following seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Since the original research, other models have become popular augmenting the Glasgow scale. These include the New Orleans Criteria and the Canadian CT Head Rule. In addition, The American College of Radiology (ACR) has established Appropriateness Criteria to help providers best utilize imaging modalities for various clinical presentations.  In the ACRs guidelines for Head Trauma imaging is not indicated for minor or mild acute closed head injury. In this patients case, the use of a CT scan was medically appropriate. On the patients initial presentation, the patient did not have a CT scan and was treated conservatively. However, her symptoms continued for 10 days. She then presented to her family physician with continuing symptoms of dizziness. While dizziness is a common ailment, one could surmise several post traumatic entities that could cause dizziness ranging from an acute disruption of the semicircular canals to temporal bone fractures. In this case, the CT was not performed acutely but 10 days following the incident due to continuing symptoms. As such, the CT scan after 10 days of persistent symptoms was medically necessary and appropriate for evaluation of the patients condition.Final Result: The reviewer determined that the services at issue were 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 diagnostic radiology 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 79-year-old male enrollee has requested the prescription medication Revatio for the treatment of his pulmonary hypertension. Findings:  The physician reviewer found that in this circumstance, maximizing cardiac treatment is usually the best approach to treating pulmonary hypertension and is preferred over the use of pulmonary vasodilators as first-line treatment. The patients elevated LVEDP with preserved cardiac output indicates that attempts at increasing diuretic dosing would be appropriate. Increased afterload reduction may also be of benefit. If the patient experiences moderate to severe pulmonary hypertension and symptoms after a decrease in LVEDP, it would then be appropriate to consider a trial of a pulmonary vasodilator.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollees autistic spectrum disorder. Findings:  The physician reviewer found that the requested speech therapy is medically indicated for treatment of this patient. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health.  Specific treatment, including speech therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. All told, speech therapy for this patient at the frequency requested is necessary to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Radicava. Radicava is U.S. Food and Drug Administration (FDA) approved to slow decline and loss of physical function in patients with amyotrophic lateral sclerosis (ALS). A study found that medical trials demonstrated beneficial improvement on functional ability and slowing clinical decline in ALS with Radicava. Study extension results published also reflected positive benefit of Radicava for treatment of ALS. The medical records provided for review support that this patient has a diagnosis of ALS. The available medical records are consistent with a progressive disorder that is progressing in terms of affecting his neurologic ability. However, the patients ALS Functional Rating Scale (ALSFRS) (ALSFRS) score should reflect a score two for walking ability, not a one, as noted in the records. A score of two is appropriate when a patient can walk with assistance. A score of one denotes only non-ambulatory functional movement. This patient is able to ambulate with the use of assistive devices. As such, all of the elements of the ALSFRS at the time medication was to be started were two or greater, which supports an indication for Radicava. Moreover, the timeframe of diagnosis was less than two years ago, as recommended by the guidelines. As such, the medical records demonstrate that the patient meets the recommendations in the medical literature for the treatment with Radicava. Therefore, treatment with Radicava is medical necessary for 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 with subspecialty certification in pain management 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 in-person evaluation and treatment by a neurologist at the skilled nursing facility (SNF). Patients in vegetative states can show behaviors such as spontaneous eye opening, but may still fail to demonstrate behavioral signs of consciousness. Findings of even minimal awareness may favorably alter prognosis and influence management such as pain management and rehabilitation interventions. Early signs of recovery of consciousness include visual pursuit and automatic movements, which requires assessment measures sensitive to these findings. Potentially confounding conditions should be ruled out and interventions to optimize arousal are appropriate for patients in persistent vegetative states. Neurologists or rehabilitation specialists generally best conduct this evaluation and management. The records reviewed do not provide an adequate clinical rationale for the requested neurology consultation for this patient. The records suggest that the provider at the subacute or long-term care facility has requested this visit based on a request made by the patients family member. There is no documented clinical question regarding diagnosis, treatment or prognosis requiring a neurologists consultation. The records indicate that the patient has undergone thorough work-up for assessment and appropriate treatment for the patients condition is in progress. Moreover, there is a lack of support for an in-person neurologist consultation rather than completion of a consultation on an outpatient basis. For these reasons, the requested in-person evaluation and treatment by a neurologist at the SNF is not medically necessary for 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: The enrollee has requested authorization and coverage for anastrozole.Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.  Aromatase inhibitors, such as anastrozole, offer effective and convenient aromatase inhibition, which correlates well with decreases in the levels of plasma estrogens. Testosterone replacement therapy is indicated when an enrollee has low testosterone. Anastrozole has been used for the treatment of male hypogonadism. Anastrozole increases testosterone levels by lowering serum estradiol (E2) levels and increasing gonadotropin levels. When used with clomiphene, anastrozole has been shown to be safe and effective to use in hypogonadal men to promote fertility. Anastrozole also has been shown to aid in sustaining the therapeutic testosterone levels in men undergoing testosterone pellet treatments. In addition, there is adequate support for use of anastrozole therapy to treat patients with hypogonadism. The records suggest that the provider recommended anastrozole to decrease the enrollees plasma estrogens in conjunction with testosterone replacement therapy. Given these findings, the requested anastrozole is medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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: A patient is requesting reimbursement and prospective authorization and coverage for residential treatment center services. Findings:  The physician reviewer found that the American Psychiatric Association treatment guidelines recommend inpatient care or residential treatment facility when lower levels of care have been tried and failed. A study evaluated the effectiveness of residential treatment for patients with anorexia nervosa and bulimia nervosa. The authors noted that there were statistically significant improvements in Beck Depression Inventory scores, and a lot of patients completing treatment showed significant improvement at discharge from intensive residential treatment. This patient was experiencing disordered eating behaviors that could not be safely managed in a less restrictive setting. The medical evidence supports the services at issue in this clinical setting. Therefore, residential treatment center services were and are medically necessary for the treatment of this patient. Final Result: The reviewer 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 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.