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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Synvisc-One injections in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient had tried and failed other conservative treatments including NSAIDs, a cortisone injection, and physical therapy, with the alternative being bilateral total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One injections in both knees were medically necessary for the treatment of this patient.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 orthopedic 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: Upheld

The patient is a 47-year-old female with chronic back and knee pain. In addition, the patient has intestinal malabsorption. She also has a history of a mood disorder. The patient reports experiencing excellent results with Actiq and she has requested authorization for continued use of the drug. The Health Plan has denied coverage for the medication on the basis it is not medically necessary for treatment of the patients chronic pain.The Health Plans denial is correct. No information has been submitted demonstrating Actiq is necessary. Although Actiq may be indicated in certain situations (i.e., breakthrough cancer pain), there is no evidence suggesting this patient requires Actiq or that all other indicated pain relief medications and therapies are ineffective or contraindicated for the patient. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested speech therapy and occupational therapy for treatment of the enrollees pervasive developmental disorder, not otherwise specified.  Findings:  The physician reviewer found that ASD is a chronic neurodevelopmental disability that requires chronic management. Myers and colleagues noted that, The primary goal of treatment is to minimize the core features and associated deficits, maximize functional independence and quality of life, and alleviate family distress. Further, Pauls 2008 article noted that young patients with ASD have deficits in social interaction, impairment of communication and restrictive, repetitive and stereotypic patterns of behavior. The author commented that, Fluency and flexibility of expressive language are key components of the distinction between high and low functioning autism in school age children or adolescents. For treatment, it was suggested that speech therapy be considered a necessary tool for social function of communication and integration in society. In addition, Landa recommends early intervention to improve cortical specialization of the patients perceptual system and assist in intra- and inter-regional integration. With regard to occupational therapy (OT), Myers and colleagues support its effectiveness in young patients with autism in assisting with self-care skills, development of play skills, improvement of attention and organization, and pre-vocational training. They also found OT to help improve social skills and prepare autistic patients for independence. OT was associated with advancement in play skills, which in turn was correlated with improvement in speech and language skills (Landa). The data indicate that communication is more than just verbal language and OT assists young patients in learning appropriate social skills and interpersonal interactions with peers through play therapy using a naturalistic approach. Given the current status of the data, speech therapy and occupational therapy are considered routine interventions for autism. Moreover, these treatments should be introduced as early as possible to improve patients neurodevelopmental deficits. There are a growing number of articles which have documented the effectiveness of these treatment modalities. All told, this patient is an appropriate candidate for these medically necessary services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued acute rehabilitation services for treatment of the enrollees intracranial hemorrhage (ICH) status post craniotomy. Findings: The physician reviewer found that the documentation does not support the requested continued acute rehabilitation services as medically necessary for treatment of this patients medical condition. The records do not indicate that the patients condition and functional status are such that the patient can reasonably be expected to make measurable improvement within a prescribed period of time as a result of the intensive rehabilitation therapy program, or that the services will be of practical value to improve the patients functional capacity or adaptation to impairments. The documentation does not reveal evidence of medical instability that requires supervision by a rehabilitation physician or that the intensity of an acute inpatient rehabilitation admission is indicated. In addition, the providers notes suggest that the patient has largely plateaued in his therapy. There has been caregiver and family education and training. All told, the patients needs can be met at a lower level of care. Thus, the request for continued inpatient acute rehabilitation is not medically necessary.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 with sub-specialty certification in neuromuscular 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 patient is a seven-year-old male with low levels of IGF-1 and IGFBP-3, a bone age delayed by two and a half to three years and a height well below the third percentile.  The brain MRI was negative for pituitary abnormalities and thyroid tests were within normal limits. Based on these findings the patients provider diagnosed growth hormone deficiency and requested authorization for growth hormone therapy. The Health Plan denied authorization based upon a determination that the therapy is not medically necessary.The clinical history and evaluation of this patient served to rule out the vast majority of etiologies for his small size with the exception of benign constitutional delay, idiopathic short stature and idiopathic growth hormone deficiency. The first two possibilities are unlikely as growth hormone deficiency/dysfunction is classically suggested by the presence of biochemical and clinical findings supportive of the diagnosis. The patient had abnormally low insulin growth factor 1 and binding protein 3 levels, both of which are growth hormone dependent, along with slow growth, delayed skeletal age and genetically inappropriate short stature. With this evidence, growth hormone stimulation tests are unnecessary for a definitive diagnosis of growth hormone deficiency.  Based upon the information set forth above, I have determined 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: A parent of an enrollee has requested authorization and coverage for spectrum sound therapy program, including the Spectrum Achieve Level One (nature music) from Advanced Brain Technologies for in-home use and pre-writing therapy program to assist with fine motor strengthening and manipulation from Handwriting without Tears for in-home use.Findings:  The physician reviewer found that there is a lack peer-reviewed literature supporting spectrum sound therapy program, including the Spectrum Achieve Level One (nature music) from Advanced Brain Technologies for in-home use and pre-writing therapy program to assist with fine motor strengthening and manipulation from Handwriting without Tears for in-home use as medically necessary in this clinical setting. Auditory Integration Training (AIT) involves a person listening to a selection of music which has been electronically modified. There are several kinds of AIT including the Berard Method, the Listening Program, the Samonas Sound Therapy, and the Tomatis Method. AIT is based on the idea that some people, including some people with autism, are hypersensitive or hyposensitive to certain frequencies of sound. AIT is designed to improve the persons ability to process sounds by re-educating the brain. A systematic review of publications in the field of AIT showed no evidence for long-term benefits. Furthermore, a study suggest that Handwriting without Tears is useful in general education and in children with Down syndrome. However, in this case there is a formal occupational therapy evaluation was not provided showing the patients current developmental level and whether an intervention to teach handwriting is appropriate. 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee has requested for substance abuse sub-acute residential treatment services for treatment of the enrollees drug dependence.  Findings:  The physician reviewer found that he has not had recent intensive outpatient or partial hospitalization program treatment. There is no indication of behavioral issues requiring 24-hour containment, and his parents have been supportive of recovery. There is no evidence in the record that he is not currently motivated for treatment. Furthermore, the record fails to establish that the patient received treatment of sufficient intensity as to warrant residential treatment, as there is no documentation supporting the patient as having received active treatment, detailing implementation of the treatment plan, or describing his response or lack thereof.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 35-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief she was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. The records indicate the patient had new and unfamiliar symptoms including pain with coitus and pinkish vaginal discharge. She is 35-years old, sexually active and of a child-bearing age. Her evaluation in the Emergency Department revealed she had bacterial vaginosis and she was discharged on Metrogel. While the patient did not have pelvic inflammatory disease (PID), according to the Centers for Disease Control and Prevention, her symptoms could have represented early or mild PID. Furthermore, UpToDate indicates that patients with even mild PID should be treated without delay since the potential consequences of withholding therapy include infertility and ectopic pregnancy. Thus, even though this patient was diagnosed with bacterial vaginosis, UpToDate also notes that endogenous bacteria from the vaginaare frequently associated with acute PID.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested residential treatment services for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that the patient had no signs of withdrawal when he was admitted to the residential treatment facility. There were no serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. Although he had a significant history of alcohol and marijuana dependence, there is no evidence he required residential treatment. The patient could have been appropriately treated at an outpatient level of care in a chemical dependency program supervised by a psychiatrist.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested the VEST airway clearance system for treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that overall, the scientific data suggests that airway clearance assistance is considered to be the standard of care for patients with cystic fibrosis. For patients who have failed treatment with manual chest physiotherapy, high-frequency chest wall oscillation (HFCWO) via the VEST system has been shown to be an effective alternative. This patient was receiving postural drainage with clapping initially, but still became infected with pseudomonas requiring treatment with a Tobi inhaler. Thus, a more effective airway clearance system was indicated to prevent recurrent infections, and the VEST airway clearance system was appropriately recommended for management of her condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a colonoscopy for evaluation of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested colonoscopy. There is a lack of high quality support in the medical literature concerning the timing of surveillance colonoscopy in this clinical setting. Surveillance at five years would be appropriate if no polyps were found in this high risk individual. However, adenomatous polyps were found in this high risk patients previous colonoscopy. In this clinical setting the appropriate surveillance should be in the 3-5 year range. Therefore, a colonoscopy is medically indicated for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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

The enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization treatment. 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.Findings: There is sufficient support in the documentation provided for the medical necessity of the services at issue in this clinical setting. The records indicated that the patient continued to be symptomatic.  The patient was described as disorganized, inattentive, and hyper-religious with persistent delusions and anxiety.  The patient was also noted to have sinus tachycardia with a documented heart rate of 130. During admission, the patient was prescribed clozapine. It should be noted that clozapine is typically reserved for use in treatment refractory cases. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014).  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history and the documentation as outlined above, the patient met CASII criteria for level 4 integrated services without 24 hour psychiatric monitoring.  This level of care is higher than intensive outpatient services.  The patients clinical status, in addition to current medical literature, support the treatment at a partial hospital program level of care as medically necessary for this patient (AACAP, 2014).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 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that per the medical evidence, hepatitis C direct antiviral therapy should be prioritized for patients who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America.  The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis or compensated fibrosis and those with severe extrahepatic manifestations of hepatitis C infection, such as leukocytoclastic vasculitis.  High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis or coexisting liver disease.  Based on the presented clinical information, the patient does not meet priority considerations for treatment.  All told, the requested Sovaldi and ribavirin for 24 weeks are not medically indicated for the treatment of this patient. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

A 34-year-old female enrollee requested authorization and coverage of a sacral nerve implant for the treatment of bladder control problems. The Health Plan denied the enrollees request indicating that the requested treatment 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 surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee requested authorization and coverage of Meridia. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 29-year-old male with a history of stuttering. He is seeking reimbursement for a SpeechEasy device. The Health Plan has determined there is no evidence supporting the need for this device and has denied reimbursement.The information submitted does not demonstrate the severity of the patients stuttering. In addition, there is limited evidence demonstrating appropriate evaluation and treatment by a speech therapist. Furthermore, the scientific evidence does not demonstrate the long-term effectiveness of the device at issue. The small studies available are not case controlled and several studies were performed with participants reading so there is little information regarding how patients would do during normal conversation. Therefore, there is a lack of clinical and scientific evidence demonstrating the equipment at issue was medically necessary for this patient. As such, the Health Plans denial should be upheld.