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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for one 60-minute speech therapy session per week for six months. This patient presents with autism spectrum disorder with associated severe expressive and receptive language delays, with severe impairment of articulation. The patients provider has recommended one 60-minute speech therapy session a week to address specific goals. Per the California Health and Safety Code section 1374(a)(3)(A), Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. On review of the available documentation, the requested speech therapy services are in accordance with the generally accepted standards of mental health care, clinically appropriate in terms of type, frequency, and duration, and are not primarily for the economic benefit or convenience of the provider or patient (Zwaigenbaum, et al.; Mulhern, et al.; Baumer and Spence). The patient has demonstrated limited progress in his articulation skills during the last evaluation period, but he was also noted to have transitioned to telehealth during the pandemic. As noted in the medical literature, children with autism spectrum disorder frequently have difficulty participating in telehealth therapy. Moreover, data is emerging on the increased stress around therapeutic service disruption in families of children with autism spectrum disorder due to the pandemic (Manning, et al.). Despite his transition to telehealth, the patient has continued to make progress in his expressive and receptive language skills, as reported by his parents and provider, and as demonstrated by improved age equivalency scores on his PLS-5 scores. All told, the requested one 60-minute speech therapy session per week for six months is medically necessary for treatment of the patient.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 in neurology with special qualification in child 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: Medical Necessity
Decision: Overturned

The patient is a nine-year-old male with a complex presentation that includes an above average IQ and the diagnoses of bipolar disorder and ADHD.  He could not be managed in his public school and was hospitalized in the acute setting prior to the admission to the Partial Hospitalization Program (PHP).  His parents are involved in a custody dispute and interactions with the father may have been curtailed.  The Health Plan terminated care at the PHP level in Arpil 2006. The patients mother has requested reimbursement and continuing authorization and coverage for the PHP services.  Her request was denied by the Health Plan based upon a determination that the services at issue were/are not medically necessary.The diagnosis of ADHD along with a bipolar disorder in a nine-year-old child is unusual and the record provided for review clearly documents the need for the PHP level of care. That criteria includes: The need to closely monitor and regulate medications on a daily basis; the need to establish coordination of care and to find the appropriate level of care in the community; the need to coordinate services with the local school district and to transfer funding via the IEP for either the continuation of PHP or the transfer to a program nearer the residence of the patient. Additionally, the situation between the mother and the father places this patient in the middle of the conflict. It is in the best interest of the patient to receive a clear message concerning his ability to communicate with his father. If the court has determined that the communication with his father is prohibited, this communication must stop. If the mother does not have the supportive documentation to prohibit communication, the father must be involved with the treatment and therapy.Due to the complexity of medication management and the need for well-coordinated care, PHP should be continued through April 2006.  This should meet the needs of the patient and allow the program to address the coordination of care issues, find an appropriate step-down placement and stabilize the pharmacological management.  Therefore, I have determined the services at issue were/are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for trigeminal nerve injections and greater occipital nerve injections. Current data on occipital nerve blocks remains mixed. Dilli and colleagues concluded that greater occipital nerve blocks did not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Inan and colleagues and found that greater occipital nerve blocks were safe and demonstrated greater efficacy than placebo in the treatment of chronic migraine. This patient has a history of chronic migraine since second grade. She has been managed with Botox, but reports incomplete symptomatic relief around the seventh week of the treatment cycle. During pregnancy, treatment with trigeminal and occipital nerve blocks reportedly provided a substantial improvement in pain and ability to function. Oral medications carry a potential risk during breastfeeding. Current literature supports trigeminal and occipital nerve blocks during pregnancy and breastfeeding, for relief of migraines, as interval therapy for Botox. Therefore, trigeminal nerve injections and greater occipital nerve injections (are medically necessary for treatment of this patient. 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 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: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female with a body mass index of 43.5. She has several comorbid conditions including hypertension, high cholesterol, gastric reflux disease, joint pain, and depression. She has a history of Hurthle cell carcinoma. The patient has undergone psychological evaluation. The findings of the evaluation did not indicate the patient is an unsuitable candidate for weight loss surgery. She wishes to proceed with bariatric surgery and has requested authorization for the procedure from the Health Plan.With a BMI of 43 and comorbid conditions such as hypertension, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested occupational therapy for one hour per week for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that review of the submitted documentation reveals that the patient did not have enough self-regulation to be able to follow the directions of the occupational therapy (OT) testing. As such, it is unlikely that working on adaptive skills will be helpful to him at this time.  Addressing behaviors and compliance is an important first step in this setting and using ABA to work on the adaptive skills, such as dressing, is key. Once the patients behaviors and compliance are improved, he may be an appropriate candidate for OT services. Therefore, occupational therapy, one hour per week, is not medically necessary at this time. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hyperbaric oxygen therapy for treatment of the enrollees left ear sudden idiopathic hearing loss. Findings:  2/3 of the physician reviewers found that the records indicate that this patient presented with sudden hearing loss. The provider recommended hyperbaric oxygen therapy for the patient. The evidence for hyperbaric oxygen therapy for treating sudden hearing loss is limited. In one study, there was only 9.6% chance of improvement with hyperbaric oxygen therapy treatment. Another controlled study found benefit only in patients treated in the first four weeks. This patient was treated with hyperbaric oxygen therapy six weeks after initial presentation. All told, there is a paucity of data demonstrating that the hyperbaric oxygen therapy provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the service at issue was 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. Credentials/Qualifications: Physician reviewer number one is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  This advantage has been especially useful in patients with extremely dense and heterogeneously dense tissue.  Therefore, the addition of breast tomosynthesis to the usual two-dimensional views was likely of more benefit for the patient than had the examination been done with two-dimensional technique alone. Final Result: Three 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: Experimental/Investigational
Decision: Overturned

A 65-year-old female enrollee has requested actinotherapy (therapeutic use of ultraviolet light) for treatment of her squamous cell carcinoma in situ and actinic keratosis. Findings:  Two physician reviewers found that in this patients case, the requested treatment has become an established treatment modality for squamous cell carcinoma in situ and actinic keratosis. Compared to other treatment methods, Levulan topical treatment plus blue light illumination offers an excellent outcome. This patient has a history of proven pre-cancers and skin cancers.  In this clinical situation, the requested actinotherapy (therapeutic use of ultraviolet light) is likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee, diagnosed with short stature, poor growth rate and low IGF-1 levels, has requested authorization for growth hormone (GH) therapy. Findings:  The physician reviewer found that GH therapy is medically indicated in that the patient exhibits obvious short stature, a decreased annual growth rate and low IGF levels. Authorization of past and present GH therapy should reasonably be conditioned upon a bone age study and clinical documentation of a positive response to the GH therapy that has been provided.
Appeal type: Experimental/Investigational
Decision: Upheld

A 19-year-old female enrollee has requested cefotaxime (Claforan) for the treatment of her Lyme disease. Findings:  Three physician reviewers found that the laboratory testing submitted does not support a diagnosis of Lyme disease in this case. Furthermore, the patient has already received the maximum recommended duration of parenteral therapy for any type or form of Lyme disease. Moreover, long-term antibiotic treatment is associated with known risks and has not been shown to be effective to treat the symptomatology with which the patient presents.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incision for implantation of cranial nerve (CPT code 64568  RT) and insertion of a chest wall respiratory sensor electrode (CPT code 0466T).Findings:  Two of three physician reviewers found that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Woodson and colleagues performed a multicenter prospective cohort study and concluded that improvements in sleepiness, quality of life, and respiratory outcomes were observed with five years of upper airway stimulation (UAS) via a unilateral hypoglossal nerve implant. Woodson and colleagues noted that serious adverse events were uncommon, and they stated that UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure treatment. Multiple additional studies indicate that hypoglossal nerve stimulation is a safe and effective treatment option for moderate to severe obstructive sleep apnea patients who have failed medical therapy. Meta-analysis has demonstrated clinically significant decreases in observed mean apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and Epworth sleepiness scale (ESS), combined with improvements in quality-of-life scales. The STAR (Stimulation Treatment for Apnea Reduction) trial also showed that UAS provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a four year follow-up.In this case, the patient has failed CPAP therapy and the severity of his disease makes him a poor candidate for oral appliance therapy. The Inspire Upper Airway Stimulation system has been shown in multiple peer-reviewed studies to be a safe and effective option for treating obstructive sleep apnea. Under these circumstances, incision for implantation of cranial nerve (CPT code 64568  RT) and insertion of a chest wall respiratory sensor electrode (CPT code 0466T) are likely to be more beneficial for treatment of the patients medical condition than any other available standard treatments.Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology, with subspecialty certification in sleep medicine, and is actively practicing. Physician reviewer 3 is board certified in internal medicine and is 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

A 53-year-old female has requested platelet rich plasma injections for treatment of her medical condition status post right knee replacement with chronic right iliotibial band friction syndrome.   Findings:  Three physician reviewers found that the patient has a reported history of right knee pain and is status post right total knee replacement. The records noted the patient with continued right knee pain and diagnosed with chronic iliotibial band friction syndrome refractory to conservative measures to include medications, physical therapy and steroid injection. A review of right knee x-rays showed acceptable alignment of hardware with no evidence of any hardware failure or malalignment. Physical examination findings documented right knee motion 5 to 85 degrees with mild varus laxity. A right knee platelet rich plasma injection was recommended. There is a paucity of peer-reviewed medical literature demonstrating the equivalence, or superiority, of platelet rich plasma injections in the management of right knee pain status post knee arthroplasty. Evidence based guidelines from Milliman do not support the use of platelet rich plasma injections as there is no proven efficacy in this clinical setting. Given the lack of scientific literature supporting the efficacy of platelet rich plasma injections in treating patients with this patients medical condition, the request for the injection to the right knee cannot be recommended as likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested authorization and coverage of an MRI of the cervical spine for treatment of shoulder and arm pain.  The health plan denied the enrollees request indicating that the requested MRI is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee has requested Sculptra injections for treatment of his lipoatrophy. Findings:  The physician reviewer found that HIV lipoatrophy is a common complication of HIV retroviral therapy. Sculptra has been approved by the Food and Drug Administration for use in cases of facial wasting directly related to this therapy. In this patients case, he has been diagnosed with lipoatrophy. Based upon the evidence provided, the patients HIV associated lipoatrophy has not resulted in a functional impairment and therefore the requested Sculptra injections are not medically necessary. With regard to whether the requested services meet criteria for reconstructive surgery, lipoatrophy is considered to be an abnormal structure of the body. This abnormal structure of the body is caused by treatment of disease or infection (HIV). The side effect of HIV treatment includes facial wasting. The requested services will not improve function, however, they are being performed to create a normal appearance to the extent possible. Based upon the photographs submitted, the requested services will offer more than a minimal improvement in the appearance of the patient. This patient has moderate lipoatrophy on the left side and mild lipoatrophy on the right side. All told, the requested Sculptra injections meet the criteria for reconstructive surgery under California law.