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

A forty-one year-old female with a history of recurrent major depression and opioid abuse is requesting authorization for enrollment in partial hospitalization program.Reviewers Findings:The reviewing physician found that there are no grounds to support the medical necessity of partial hospitalization program services.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 23-year-old female enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of her diabetes. Findings:  Two physician reviewers found that the 72-hour continuous glucose monitoring system (CGMS) in contention was approved by the Food and Drug Administration in 1999. Since that time there have been many articles in peer-reviewed journals that have shown improvement in blood sugar control using this system. The device has been used in endocrinology practices as a standard of care for patients whose blood sugars are not well controlled despite frequent self monitored blood glucose by fingerstick. The use of CGMS in this setting was medically appropriate and clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lorazepam and Norco. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. Before prescribing opiates, a risk assessment should be performed as well as setting goals for pain management. Chronic use of opiates for non-malignant pain is not recommended. The patient is also on a benzodiazepine, which would put her at increased risk of overdose. It is the standard of care to see a patient with enough frequency to detect aberrant behavior, note changes in medical history or physical status. There is a lack of support for the requested medications in this clinical setting. Therefore, lorazepam and Norco are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in 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: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive and receptive speech of approximately 40 to 50% per the Rossetti Infant-Toddler Language Scale and the Developmental Profile III.  Speech therapy is indicated with any delay greater than 25%. Extensive review of the literature, including the meta-analysis by Law and colleagues, noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately 50% of children delayed at two years of age catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children involved in early intervention services with parental interaction and teaching show stronger language skills than children who did not receive early intervention. Children who participate in speech-language treatment show better improvement as compared to children who have no treatment.  This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The representative of the patient has requested reimbursement for air ambulance and ground ambulance transportation services for treatment of the enrollees stage III cervical cancer. Findings:  The physician reviewer found that Air ambulance is considered medically necessary under certain circumstances. Emergency circumstances include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport, when the time needed to transport the patient by land poses a threat to a patients survival, or when the proper equipment needed for the patient is not available on a land ambulance. Air ambulance may be appropriate to transport a patient from one facility to another if the patient requires a higher level of care than the sending facility can provide. In such cases, air ambulance is needed to transport the patient to the closest facility capable of providing the necessary care for that patient. Air ambulance transport is not indicated for purposes of patient request or convenience. In this case, the patient was not transferred emergently. The transport was arranged in advance. The patient was not transferred from one facility to another to receive a higher level of care. She was discharged and being transported home per her request. There are multiple hospice facilities in Los Angeles capable of providing hospice and palliative care. She was using patient controlled anesthesia for pain control and did not receive any intravenous medications during transport. She was using low dose supplemental oxygen and did not require titration during transport. This patient could have been transferred by stretcher car or gurney van to a hospice facility in closer proximity to UCLA. Criteria for air ambulance transport are not met in this case. Thus, the ground ambulance services provided were medically necessary while the air ambulance services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were 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 emergency 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.   Final Result: Two reviewers determined that the services at issue were 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:   All three reviewers are board certified in diagnostic radiology and are actively practicing.  All three 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: Overturned

The patient is a 51-year-old female diagnosed with Adjustment Disorder - mixed anxiety and depression, and Generalized Anxiety Disorder.  She has been seen in psychotherapy for about one year, due in part to family stressors. The stressors include parenting three teenage children, a husband who is depressed and drinking excessively, and a former spouse, the biological father of her children, who is deaf, brain damaged, and now homeless. The patients therapist notes that she is making excellent use of psychotherapy and tends to typically downplay the extent of her symptoms. The patient has indicated that therapy has allowed her to face her life challenges by understanding them more clearly, without the use of medication, alcohol, or other destructive means. The patients request for authorization of additional therapy sessions was denied based upon the Health Plans determination that continued therapy is not medically necessary.While the enclosed notes are fairly topical in some areas, others review the pertinent issues with which the patient is struggling. Though it is unclear to what extent there are acute stressors, there are clearly significant chronic ones that persist. The patients diagnoses of Adjustment Disorder and Generalized Anxiety Disorder appear valid and are not disputed by the Health Plan.  The literature cited supports the need for therapy with adjustment disorder alone, and it follows logically that therapy for adjustment disorder combined with anxiety disorder is at least equally important. Therefore, I have determined that 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: Overturned

This patient is a 12-year-old male with a diagnosis of autism with significant speech delays including severe moderate to severe language processing and auditory memory defect. The patient has difficulty in semantic organization and word finding. He has been receiving speech therapy for six years. The speech therapist has requested authorization and coverage for continued speech therapy services. In addition, a request has been made for coverage for the patients previous speech therapy. The Health Plan has determined that speech therapy has not been medically necessary for treatment of the patients medical condition since July 2003.Review of the relevant medical literature reveals there are no placebo-controlled, blinded clinical trials evaluating speech in autism. However, standard of care for patients such as this patient is speech therapy to treat their language skills. The submitted documentation provided by the patients speech therapist provides objective clinical data (i.e., CIEF-3, TOPS, LPT), which reflect that this patient has been making slow, steady progress over a two-year period ending in July 2004. As such, the speech therapy the patient received since July 2003 was medically indicated. Furthermore, given the chronic nature of autism, the patient can be expected to continue to show improvement with additional speech therapy. Therefore, the patient should continue to receive speech therapy two times per week, with re-evaluation every six months. Therapy should continue until objective data verifies a plateau of skills or the deficient skills fall within normal. Based upon the information set forth above, I have determined that 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: An enrollee has requested reimbursement for the cervical/thoracic facet joint block for treatment of the enrollees cervical facet spondylosis.  Findings:  The physician reviewer found that based on the documentation submitted for review, cervical/thoracic facet joint block provided has not been established as medically necessary for treatment of the patients medical condition. Researchers support injections as an intervention for neck pain. However, the Health Plans recommendation for failure of conservative non-operative therapy management for a minimum of six weeks in the last six months prior to facet injections is medically reasonable and appropriate in this clinical setting. In this case the records do not show that the patient has failed to respond to conservative non-operative therapy management for a minimum of six weeks prior to facet injections. The patient presented with a two-week history of pain and underwent cervical/thoracic facet joint block. As such, the record does not demonstrate failure of conservative non-operative therapy of six weeks. Final Result: The reviewer determined that the service at issue was 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 anesthesiology with sub-specialty certification in 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: Overturned

This patient is a 56-year-old male who had acute myocardial infarction with cardiac arrest and subsequent anoxic encephalopathy 18 months ago. The patient was treated with angioplasty and stent of the diagonal branch and placement of AICD. Cardiac echo and nuclear scan showed infarction of the anterior and lateral walls with EF of 20 to 25 percent. The patient is on eight medications to control hypertension and protect him from congestive heart failure. The patient has care provided mainly by his wife as he appears to function at the level of a six to eight-year-old as a result of his anoxic encephalopathy. The patients cardiologist recommends evaluation for cardiac transplant due to ischemic cardiac myopathy. The transplant cardiologist states that the patient is symptomatic enough to warrant evaluation for orthotopic heart transplant, but he had concerns regarding the patients neurologic status and peripheral vascular status (although the patient is asymptomatic for claudication).The Health Plan denied the request for the heart transplant evaluation based upon concerns over the patients ability to follow a structured medical regimen post transplant. The transplant cardiologist sates that he has concerns about the patients neurologic status but the transplant cardiologist did not state that the patient was not a candidate for a transplant. The evidence submitted demonstrates that clinically the patient is an appropriate candidate for a transplant evaluation. The patient has been on medical management for his ischemic cardiac myopathy of eight medications successfully and with the patients wifes assistance should be able to have a cardiac transplant evaluation. Based upon the results of this evaluation, it would be the transplant team to decide if the patient is a candidate for transplant. There is no evidence of any psychological or social contraindication such that the patient with the wifes assistance would be unable to follow a medical regimen post transplant.Based upon the information set forth above, I have determined the requested evaluation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee has requested reimbursement for services of an assistant surgeon during a bilateral brachioplasty and assistant surgeon services for abdominoplasty treatment of the enrollees excess skin. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue.  Surgeons call upon assistants to utilize problem-solving skills that are only developed through medical and surgical training.  The primary surgeons decision about who is most appropriate to serve as an assistant at surgery may be based on factors such as the nature of a specific operation, the unique medical circumstances of an individual patient, the availability of appropriately trained physicians or non-physician staff, or ready access to other appropriately trained specialists.  An assistant surgeon is medically necessary if the care provided or service rendered by the assistant requires the credentials and technical skills of the assistant.  Specifically, an assistant surgeon is indicated when the service provided could not be fulfilled by lesser trained providers employed in the operating room. Given the magnitude of this patients operation and amount of suturing required, an assistant surgeon was medically necessary for the services at issue.  All told, assistant surgeon services for bilateral brachioplasty and assistant surgeon services for abdominoplasty were medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the scientific literature strongly supports speech therapy for autistic children. Myers, et al. stated that people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services.  Turner, et al. performed a controlled study comparing autistic children, who did and did not receive speech therapy, and concluded that those patients who did receive therapy had far greater communication skills than those who did not receive speech therapy. The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  All told, it is medically necessary that this patient receive individual speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mesalamine suppositories. The American Gastroenterological Association (AGA) guidelines on the management of mild to moderate ulcerative colitis suggest a trend favoring rectal mesalamine over oral mesalamine for induction. For patients who opt for rectal therapy, the AGA recommends mesalamine suppositories, stating, Suppositories are generally well tolerated, with few treatment-related adverse effects and better retention than enemas. In reviewing cases of patients with ulcerative proctitis who were initially treated with oral 5-aminosalicylate (5-ASA), mesalamine suppository, or mesalamine enema, researchers noted that treatment escalation was common in patients initiated with oral 5-ASA treatment. Given that guidelines support rectal mesalamine for the treatment of ulcerative colitis, the requested medication is medically indicated. Therefore, mesalamine suppositories are 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 internal medicine with sub-specialty certification in gastroenterology 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 32-year-old male enrollee requested authorization and coverage for Diflucan or Lamisil.  The health plan has denied this request indicating that neither of the requested medications is medically necessary for treatment of the enrollees Onychomycosis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that either of the requested medications is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested a Real-Time Remote Heart Monitor for an evaluation of his paroxysmal atrial fibrillation. Findings:  Two physician reviewers found that there is no evidence that this short period of continuous monitoring is more effective than either standard periodic Holter monitoring or patient-activated ambulatory event monitoring. Since this patient was symptomatic, a self-activated event recorder to record heart rhythms during symptoms would have been more appropriate for evaluation of this patient. Additionally, recognition of asymptomatic intermittent atrial dysrhythmias at this time should likely not change the treatment approach based upon current practice guidelines.