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

The patient is a 10-year-old male with the diagnosis of Aspergers syndrome. He currently attends a special school and has attended a camp and group sessions to improve his socialization over the last two years. A review of the notes from the peer-involved group therapy demonstrates initial progress and improvement in most of the target areas with an apparent plateau. The parents request that the Health Plan provide coverage for this group socialization program, but the request has been denied on the basis that the therapy is not directed toward acute mental health issues and is not medically necessary.Though a review of the literature suggests that socialization with behavioral modification can be helpful in Aspergers syndrome, in this case the patient has been receiving peer-involved group therapy for several years and seems to have reached a plateau. Given the documentation provided, continued therapy was not medically warranted beyond July 2005.  Additionally, such therapy has historically been included as part of the students school curriculum through the IEP program. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for inpatient psychiatric hospitalization for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that Although the patient denied acute suicidal ideation, treatment could not have reasonably been conducted at a less restrictive setting because less intensive treatment would have resulted in inadequate care. The patient had neither resolved the illness burden that prompted the admission nor consolidated the treatment gains necessary to successfully follow through with outpatient treatment services. The patient had a refractory affective disorder.  The patient  had an anxious-depression, the combination of which is difficult to treat and associated with poorer outcomes. The patient  was psychiatrically hospitalized two weeks prior to this admission.  The patient  had trialed many medications.  The patient  suffered from opioid misuse which further compromised her prognosis.  The patient reported increased neck pain. The patient was feeling hopeless. The patient's appetite had decreased and her sleep was poor.  It was further noted that the patient's energy level was low, mood was anxious and was depressed. The provider began considering the possibility of electroconvulsive therapy and transcranial magnetic stimulation. The patient was lethargic and depressed, mood remained irritable, with little improvement. Nursing notes indicated that the patient was anxious, isolative and restless. The acute setting remained safe, appropriate and reasonably expected to improve the patients condition while preventing a more serious episode of illness. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Specifically, 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name medication, Wellbutrin XL 150 mg. Saiz Ruiz and colleagues found that patients who could benefit from the clinical effect of bupropion included patients with inadequate response to previous treatments. The U.S. Food and Drug Administration approves the use of Wellbutrin for the treatment of major depressive disorder. In this case, the patient has major depressive disorder. She has found Wellbutrin XL effective for stabilizing her symptoms such that she was able to reduce and stop medication. Given that she has tried and failed alternative medications, including generic bupropion, and has responded well to Wellbutrin XL in the past, the requested medication is medically indicated for this patient. Therefore, brand name medication, Wellbutrin XL 150 mg  is 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 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

The patient is a 53-year-old female who was morbidly obese prior to a 100-pound weight loss. She underwent body sculpturing procedures and an augmentation mammaplasty in the past with correction of a left tubular breast deformity. The patients plastic surgeon has requested authorization for repositioning and possible exchange of the patients breast implants and a mastopexy. The Health Plan has determined the requested services are not medically necessary for treatment of the patients condition.Examination of the submitted medical records and photographs reveals the appearance of spherical contracture of the left breast. This constitutes medical necessity for left breast implant removal and capsulectomy or capsulotomy, whichever is indicated at the time of the operation. At the time of the procedure it may be determined a new implant is required; if so, new implant placement should be authorized. However, there is no evidence of a functional impairment involving the right breast. As such, repositioning/exchange of the right breast implant is cosmetic in nature and not medically necessary. Furthermore, the submitted photographs and clinical information do not demonstrate a mastopexy is medically necessary. Based upon the information set forth above, I have determined that repositioning of the left breast implant with possible exchange of the implant is medically necessary for treatment of the patients medical condition. However, repositioning and exchange of the right breast implant and a mastopexy are cosmetic in nature and not medically necessary for treatment of the patients medical condition. Therefore, the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested thighplasty and suprapubic area plasty with skin excision for the treatment of her chronic skin ulcerations status post bariatric surgery. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the requested surgery is reconstructive in nature. The patient has generalized skin laxity associated with weight loss. The photographs provided do not demonstrate that the degree of excess skin is so severe as to constitute an abnormal structure of the body. In the absence of evidence that the patients excess skin condition constitutes an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease, the proposed surgery does not meet the definition of reconstructive surgery as defined by California law. Concerning the medical necessity of the proposed surgery, there is insufficient evidence of a functional impairment to support a thighplasty and suprapublic area plasty. The requested surgery has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the accuracy of the patients history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of infections in the thigh folds. Furthermore, photographs documenting cellulitis, ulcerations or rashes were not submitted. The plastic surgeons office notes describes a history of thigh and mons pubic infections but do not document any medically supervised attempts at conservative management of this condition. The medical records do not provide any documentation in the form of frequent physician visits to the patients primary care physician or plastic surgeon for the management of ongoing clinically significant dermatologic problems that have either: 1) never responded to topical therapy; or 2) despite initial response, have recurred and caused significant functional impairment.
Appeal type: Medical Necessity
Decision: Overturned

A 69-year-old male enrollee requested chiropractic treatment for medical treatment of his back and leg pain.  Findings:  The physician reviewer found that the initial chiropractic treatments were medically necessary for treatment of the patients spine. However, subsequent chiropractic treatments were not medically necessary. Initially, the patient was sufficiently evaluated through physical examination and review of imaging to formulate a diagnosis and treatment plan. However, only the initial 12 chiropractic treatment visits were medically necessary for treatment for the patients medical condition. The treating chiropractic office notes after that point lack the necessary clinical documentation to warrant the need for continued treatment. The chiropractic treatment records do not show orthopedic or neurological re-testing was performed. Moreover, there is a lack of adequate evidence in the peer-reviewed literature to support the use of spinal decompression. Based on the lack of clinical documentation for continued treatment and the above-cited chiropractic guidelines, the initial chiropractic treatments were medically necessary for treatment of the patients medical condition, however not thereafter.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 22-year-old female with long-standing bulimia nervosa.  Her restrictive eating patterns began at age 12, and at the time of referral to residential treatment she was given to restricting her intake to about 600 calories. The patient reported purging after eating breakfast, restricting throughout the day, and then eating dinner and purging afterwards. She noted a fear of weight gain and strong dislike of herself. She also noted acceleration in her eating disorder accompanied by significant guilt and depression secondary to an abortion she had about a year and a half earlier.  The patients depression had previously been treated with Lexapro, Effexor-XR, and Zoloft but she reported little benefit from the medications. When referred to residential treatment in August 2004, the patient was not actively involved in psychiatric treatment and was not receiving any medications. During residential treatment, the patient was assessed as significantly depressed and she received no antidepressants. At admission, she rated her depression as 3/10 in contrast to much stronger depressive feelings in the year 2003, when she rated her depression as 9/10. She also noted that she liked herself better than she used to and felt better, in part, due to a new set of friends at work. Residential treatment included a variety of therapies and she was initially noted to have made good progress but later she grew wary of any further weight gain. All of the formal psychiatric evaluations describe the patient as attentive, affectively unremarkable, speech conversational and kinetics unremarkable. Her insight into her eating disorder was judged as modest to fairly good. The patient did not engage in purging while in the residential program.  The Health Plan denied authorization for the residential treatment admission and continued stay based upon their determination that it was not medically necessary.While the patient unquestionably suffered from bulimia nervosa, there is no evidence she was involved in any particular outpatient psychiatric treatment program prior to the referral for residential treatment. She was working about 30 hours per week and was not notably underweight. She was noted to be highly motivated to participate in treatment and she was relatively unencumbered by depressive symptoms. It is unclear why a concerted course of outpatient treatment was not recommended. Treatment options may have included an intensive outpatient program (IOP) or a partial hospitalization program. If programs such as these had failed, a referral to residential treatment would have been a reasonable next step. In this situation however, the referral to residential treatment was premature. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested Dynasplint devices for treatment of her status post bunionectomy with first metatarsal neck osteotomy of both feet.  Findings:  Three physician reviewers found that the patient was treated with bilateral Dynasplint devices after surgery.   She received Dynasplint devices to aid in regaining full range of motion of her toes. The Health Plan has denied reimbursement for Dynasplint devices and maintains that the devices at issue were investigational, and this is the subject of the appeal.  At this time, there is insufficient clinical evidence to support the postoperative use of the Dynasplint device following bunionectomy.  The available studies do not demonstrate a change beyond usual care, as there is a lack of control groups as a comparison.  At this time, there is insufficient evidence supporting the use of a Dynasplint device in this patients case.  The medical literature has not established that the use of a Dynasplint device following bunionectomy is superior over other treatment alternatives.  Therefore, the Dynasplint devices at issue were not likely to have been superior over other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested for endovenous laser ablation of the accessory greater saphenous vein of the left leg for treatment of his varicose veins.  Findings:  Two physician reviewers found that there is inadequate evidence in the scientific literature that branch vein ablation is superior to standard therapies. Endovenous ablation has been primarily studied in the setting of great and small saphenous veins. It is not appropriate to extrapolate the results of such studies to predict superior results with accessory vein ablation. Further, there is no evidence that endovenous ablation of the accessory branch provides any advantage over standard therapy, such as stab phlebectomy, which would also allow treatment of other varicosities on the same leg at that time. As stated previously, ablation also carries the risk of skin burning if the branch is superficial, which is not present with stab phlebectomy.All told, the submitted duplex images do not demonstrate a contraindication to standard treatment options available in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested continued treatment in an intensive outpatient program (six days per week) for treatment of her anorexia nervosa, posttraumatic stress disorder and major depressive disorder.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The medical records provided do not outline past treatments tried and failed.  This patient was diagnosed with major depressive disorder.  However, the records do not document that she was prescribed an antidepressant.  The patient was diagnosed with posttraumatic stress disorder, but she was not prescribed a serotonergic-enhancing medication or involved in an evidence-based trauma therapy, both of which represent first-line interventions for the disorder.  Regarding her eating disorder, the record evidenced a significant element of chronicity and stability.  She had no laboratory abnormalities or medical complications, and her vital signs were stable.  There was no mention of outcomes of comprehensive outpatient services consisting of family therapy, individual therapy, nutritional counseling and pharmacotherapy.  All told, continued treatment in an intensive outpatient program (six days per week) from the dates specified forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested a bone anchored hearing aid for treatment of his unilateral hearing loss. Findings:  The physician reviewer found that this patient has unilateral congenital deafness and now has mild to moderate sensorineural hearing loss in the opposite ear. While the BAHA system was originally devised as a way to enhance hearing in ears that could not benefit from conventional aiding, (i.e., chronic middle ear disease, congenital malformation), the use of this system has expanded to include correction of unilateral hearing loss after resection of acoustic neuroma. These latter patients have presumably lost serviceable hearing in the operated ear, but continue to have a contralateral ear with fairly normal hearing. This patient has had unilateral hearing since birth. He now has gradually progressive worsening in his hearing ear. The BAHA device, although helpful in improving directionality, will not be of significant value in this setting since its efficacy will diminish as the patients hearing loss progresses in the hearing ear. There is no documentation in the submitted records that the patient has had a trial of conventional hearing aid use in the hearing ear. A trial with conventional amplification to the hearing ear is the next appropriate step in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 19-year-old male who has keloids and/or hypertrophic scars of the face, possibly secondary to pseudofolliculitis barbae. Intralesional Kenalog injections and silastic gel sheeting treatment resulted in a flatter appearance of the lesions. The patient does not wish to receive additional intralesional Kenalog injections. Instead, he has requested authorization for laser hair removal. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary.The Health Plans denial should be upheld. According to the submitted clinical records there are no hairs growing within the scars. If there is no hair to remove, there is no value in performing laser hair removal and as such, there is no medical justification for the procedure. Additional treatment should be focused on the scars themselves rather than on hair removal. Therefore, I have determined the requested procedure 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 patient is a 17-year-old female who has a long history of behavioral health problems. On 11/20/03, the patient was admitted to an inpatient level of care. She was then stepped down to a residential level of care on 1/29/04. A request has been made for reimbursement for inpatient services received from 11/20/03 through 1/28/04 and for residential treatment services received from 1/29/04 through 4/9/04. The Health Plan has denied this request indicating the services at issue were not medically necessary.Review of the submitted clinical information demonstrates inpatient services were medically necessary. However, the clinical information does not demonstrate residential services were medically necessary. Prior to the inpatient admission, the patient had been receiving regular dietary and psychiatric counseling for at least a year. Despite this therapy, the patients condition was deteriorating with continued depression, self-harm, and acting out along with purging. The patients condition in November 2003 coupled with her treatment history warranted an inpatient admission. In fact, it appears the Health Plan recommended inpatient care for the patient. Records from the inpatient stay demonstrate improvement in the patients condition with stabilization and some level of insight. At the time of discharge from inpatient care, the patient was stable and records demonstrate residential care was not medically necessary. Based upon the documentation provided from the patients residential treatment, it is difficult to evaluate the patients clinical progress, as psychiatry visits were few and documentation brief. Furthermore, there is no objective clinical evidence demonstrating the patients condition was such that she required a residential level of care. Based upon the records provided, the patient could have been treated at a less intense level of care after discharge from inpatient care.Based upon the information set forth above, I have determined although inpatient care was medically necessary, residential care was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections for treatment of her medical condition. Findings:  The physician reviewer found that Orthovisc is a high molecular weight hyaluronan. Most experts agree that its use is best in those patients with osteoarthritis (OA) of the knee who have not responded adequately to or tolerated acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) nor received significant relief from intraarticular glucocorticoids. In this case, the medical records submitted for review document failure of conservative therapy. The patient has received a previous steroid injection to the knee with no response. In addition, the documentations submitted for review demonstrates osteoarthritis of the knees. For the reasons provided, the medical necessity for Orthovisc injections has been established in this clinical setting.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 internal medicine and allergy and immunology with sub-specialty certification in rheumatology 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 parents of a six-year-old male enrollee have requested for speech therapy for treatment of his articulation disorder. Findings:  The physician reviewer found that this patient did suffer an injury the results of which could require speech therapy, this patients condition is not at such a level that individual speech therapy is medically necessary. The speech therapy assessments do not demonstrate a significant speech disorder requiring individual speech therapy.