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

A 52-year-old male enrollee has requested Bepreve eye drops for treatment of his  eye allergies.  Findings:  The physician reviewer found that Bepreve eye drops are medically necessary for treatment of the patients medical condition. Chronic allergic conjunctivitis is often responsive to over-the-counter antihistamine drops such as Pataday. When these become ineffective, use of low-strength steroid preparations are indicated. The problem with long-duration steroid drops is the chance of developing glaucoma and/or cataracts. Therefore, if no relief is achieved with any of the aforementioned drops, Bepreve eye drops are reasonable and medically necessary. Therefore, the medical necessity for the requested medication has been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female has requested an MRI of the left breast for evaluation of her left breast nodule.  Findings:  Three physician reviewers found that the patient is underwent a screening mammogram nine months ago.  The report noted a 12mm oval nodule in the left breast at the 12 oclock to 1 oclock position and an asymmetry in the left breast at the 12 oclock position.  Additional imaging was recommended. An ultrasound of the left breast was subsequently performed.  Both areas of concern were evaluated, and the providers assessment was benign findings.  Per the medical records, the patients mother had been diagnosed with breast cancer.  In this clinical setting, the requested MRI of the left breast is not likely to be superior over other available methods of evaluating this patient.  In this patients case, additional imaging was recommended following the mammogram.  Both lesions seen on mammogram were evaluated with ultrasound, with benign findings.  Per the submitted documentation, the patients mother was postmenopausal when she was diagnosed with breast cancer.  There is a lack of evidence indicating that the requested diagnostic procedure will be of benefit in this patients case.  The current medical evidence does not support the requested MRI of the left breast in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her uterine cancer.  Findings:  The physician reviewer found that while it is true PET/CT has not proven of great value in standard cases of endometrial epithelial cancer, this patient has a diagnosis of carcinosarcoma of the endometrium which is a completely different tumor. The common endometrial cancer metastasizes to regional lymph nodes, but the sarcomatous feature of this patients tumor is known to spread via a hematogenous route. This difference makes detection much more challenging with metastases often appearing in far distant sites. Thus, despite the fact that her tumor was confirmed at stage 1A at initial diagnosis, a thorough surveillance for distant metastasis for several years is reasonable. Instead of scanning with magnetic resonance imaging (MRI) or CT in specific regions, the PET/CT will offer a more comprehensive approach in evaluating all organs with a single test. Therefore, the PET/CT requested in this case should be approved as it has been demonstrated to be medically necessary for further evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested rehabilitation services for treatment of his substance abuse.  Findings:  The physician reviewer found that the records indicate that the patient was able to achieve sobriety for several weeks prior to his admission to this program. There is no indication of serious medical sequelae related to his drinking or risk of withdrawal. He had not failed treatment in a less intense setting and there is no evidence that his living situation was subversive to sobriety. There were no documented behavioral issues which necessitated skilled observation and containment on a 24/7 basis. Furthermore the level of programming is not commensurate with intensity of services criteria for a 24-hour setting, as the patient received less than three hours of treatment per day. The data reviewed are inconsistent with American Society of Addiction Medicine guidelines and American Psychiatric Association guidelines as the patient could have been safely and effectively managed on an ambulatory basis during the time period at issue.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested x-rays of the soft tissue, sinus x-rays and computer muscle testing for an evaluation of her chronic headaches accompanied by atypical facial pain, temporomandibular joint sounds on opening and closing of the jaw, dizziness and bilateral cervicalgia. Findings:  The physician reviewer found that the current, well-accepted, universally performed test to identify the presence or absence of temporomandibular disorders or one of its subcategories is a comprehensive evaluation of the patients history and clinical examination. This is considered the gold standard by some. There are many other tests and diagnostic studies that are employed in the treatment of temporomandibular disorders, such as surface/needle EMG, thermography, sonography and mandibular kinesiology (jaw tracking). However, the evidence for the use of these modalities in the differential diagnosis and monitoring of temporomandibular disorders and orofacial pain is not supported in the literature. At present, the well-accepted standard for the diagnosis of temporomandibular joint disorders and orofacial pain is patient history and clinical examination, and, when indicated, select temporomandibular joint imaging. It is also accepted that obtaining temporomandibular joint radiographs to determine whether condyles translate during jaw opening is unnecessary, as that information can be obtained by physical examination. X-rays of the soft tissue, sinus x-rays and computer muscle testing were not medically indicated or appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for Autonomic nervous system testing. The records document that this patient presented to her provider with symptoms of fatigue and lightheadedness. She was diagnosed with a disorder consisting of autonomic dysfunction in the spectrum of postural tachycardia. The patients symptoms were consistent with orthostatic intolerance of unknown etiology. In this clinical setting, autonomic screen testing is a well-established battery of tests to evaluate patients when the underlying cause is unknown. The purpose of the tests is to confirm that the patient has autonomic dysfunction, determine the severity of the dysfunction, and determine whether the patient has underlying autonomic failure causing the symptoms. There are no options available to evaluate a patients symptoms other than autonomic testing and the results of these tests are actionable. There is longstanding support for these tests from the American Academy of Neurology (AAN), American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), and American Academy of Physical Medicine and Rehabilitation (AAPMR) for this type of testing in evaluation of autonomic dysfunction of unknown etiology. Moreover, recent reviews in the medical literature also support autonomic nervous system testing as generally accepted standards of medical practice in this clinical situation. All told, the autonomic nervous system testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the autonomic nervous system testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in neurology with special qualification in child neurology and are 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: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male has requested a speech and language evaluation for the evaluation of speech and language deficits.  Findings:  The physician reviewer found that The speech therapy evaluation identified expressive language delays, articulation delays and tongue thrusting. It does not appear these issues were previously identified or addressed during past therapy. In addition, there is a family history of dyslexia, indicating there may be an inherited component to the patients speech and language deficits. It is reasonable to re-evaluate when work begins with a new therapist and to establish appropriate treatment goals.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for continued physical therapy services for treatment of her right sacroiliac joint dysfunction.  Findings:  The physician reviewer found that per Medicare guidelines, a patients prognosis should not be the sole factor in determining whether a service is skilled. Rather, the crux should be whether the services of a skilled therapist are needed to treat the illness or injury. Considering the description of this patients symptoms and her prior treatments, it is likely that the manipulative treatments required to manage her condition can only be safely performed by a skilled physical therapist. As recommended by LasLett for patients with this chronic condition, Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Suction-assisted protein lipectomy (SAPL). Based on the available documentation, the SAPL was medically necessary for treatment of this patient. The provider noted that the patients lymphedema was causing functional issues with an impact on his ability to work and perform his activities of daily living. He has attempted conservative therapy with manual lymphatic drainage and compression therapy without substantial improvement. Current peer-reviewed medical literature supports an indication for SAPL in this clinical setting. Researchers noted that, lipoaspiration for treatment of lower limb lymphedema, followed by controlled compressive therapy (which must be continued to maintain the reduction volume reached by lipoaspiration), can potentially improve late stages 2 and 3 of chronic lymphedema when conservative therapy is ineffective. This procedure has been demonstrated to improve functionality and quality of life and decrease the rate of infection in lower limb lymphedema. Further, medical literature reported that, Several studies have confirmed the efficacy and long-term stability of large-volume suction assisted lipectomy debulking for reducing limb volume to that similar to the unaffected side for both the upper and lower extremities In addition, the incidence of cellulitis is reduced dramatically postoperatively. Given these findings, the SAPL was medically necessary for treatment of the patients medical condition. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The records provided for review demonstrate that this patient has an enlarged leg secondary to lymphedema. This condition is related to prior infection and a surgical procedure that remove the patients inguinal lymph nodes. The surgery was performed to improve function and activities of daily living and would improve the patients appearance since the legs will be more symmetrical. Therefore, the SAPL was also reconstructive in nature for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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

The patient is a 16-month-old male whose parent wished him to be circumcised in the immediate neonatal period. However, there was concern for hypospadias and he could not have a circumcision prior to an evaluation by a pediatric urologist, which occurred several weeks later. The patient was found to have normal penile anatomy and is now medically cleared for circumcision. His parent wishes to have the circumcision performed at this time and has requested authorization from the Health Plan. The Health Plan denied the request, citing a lack of medical necessity.The American Academy of Pediatrics 1999 Task Force on Circumcision concluded that parents should determine what is in the best interest of the child after being counseled regarding the potential benefits and risks of this elective procedure. That is the situation in this case - the parent wishes to have her child circumcised. The Health Plan would have authorized the procedure as a covered benefit in the neonatal period, but although the parent wanted it performed then, concern for a potential penile deformity precluded circumcision at that time. The patient is currently in an appropriate condition to have the procedure performed. The circumcision, which was delayed during the neonatal period due to medical reasons, should be authorized and performed. Therefore, I have determined that 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: An enrollee has requested authorization and coverage for clonazepam dispensed on a monthly basis. Findings:  The physician reviewer found that although appropriate patient-centric care may ultimately arrive at rather uncommon medication regimens, there is no longitudinal evidence in the medical record of systematic progression through standard pharmacologic therapies, applied in conjunction with evidence-based non-pharmacologic interventions, to support the medical necessity of clonazepam therapy dosed at 6 mg daily and dispensed on a monthly basis. The patient has been diagnosed with multiple anxiety disorders. However, there is no evidence that standard therapies, such as alternative medication strategies, treatment with cognitive behavioral therapy, or chemical dependency and/or psychiatric consultation, has been exhausted. Further, the patient is prescribed multiple respiratory sedating medications, including benzodiazepine. Recognizing the recent tripling of emergency room visits and increased death rate of patients prescribed both a benzodiazepine and an opioid, the U.S. Food and Drug Administration issued a warning of the serious risks associated with the combined use of certain opioid medications and benzodiazepines. Based on the documentation provided, clonazepam dispensed on a monthly basis has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially upheld. Credentials/Qualifications: Physician reviewer number two 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:  An enrollee has requested a 12 week course of Harvoni for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that denying treatment for a chronic disease such as HCV because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. Harvoni is a one-pill drug that is used without ribavirin and has no serious adverse effects or contraindications. The U.S. Food and Drug Administrations approved use includes patients with early stage disease. In addition, treatment delays may decrease the benefit of sustained virologic response. In a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. In addition, national joint guidelines recommend Harvoni for 12 weeks for treatment-experienced chronic HCV patients with genotype 1a. Therefore, the request for Harvoni for 12 weeks is medically necessary for this patient. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two 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: Overturned

The parent of a 14-year-old female enrollee has requested acute inpatient psychiatric hospital treatment for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the medical records indicate the patient was admitted on a 72-hour hold on an involuntary basis via ambulance following self-inflicted cuts to her face and chest and verbalized suicidal ideation. This patients history is positive for suicidal gestures in the past with cutting. She was also noted to have severe family stressors. The provider noted impaired judgment on admission with a global assessment of functioning (GAF) of 20. The provider noted depressed mood and guarded behavior in the progress notes, and ordered checks on the patient every 15 minutes. The treating psychiatrists notes indicate the patient was unable to come up with any strategies besides cutting, she continued to display depressed mood, and had flat affect. The patient was able to identify one coping skill and it was determined she could return home. She was discharged the next day. Acute inpatient psychiatric hospitalization from was medically necessary and supported by the submitted medical documentation. The patient was a danger to herself, she engaged in high risk self-harm behavior, there were severe family stressors, and there was a history of previous self-harm behavior. She required containment and treatment in an acute 24-hour setting. This conclusion is consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines and CALOCUS placement criteria.
Appeal type: Urgent Care
Decision: Upheld

A 33-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in danger without immediate medical attention. This patient was comfortable and sleeping in the emergency department. There is no documentation to support that this patients symptoms were of such severity that a prudent layperson would believe he required immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an male enrollee has requested authorization and coverage for circumcision for treatment of the enrollee, who presented for circumcision. Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) recently published a policy statement regarding circumcision, supporting the procedure. The AAP has determined that the benefits of circumcision outweigh the risk, recommending circumcision for any neonatal infant in whom there are no medical contraindications, accept for family preference. The Center for Disease Control (CDC) has taken this stance even further, recommending discussion with adolescent and adult men regarding benefits and risks of circumcision surgery. The benefits include prevention of urinary tract infection, acquisition of human immunodeficiency virus, transmission of some sexually transmitted infections, and penile cancer. Based on these current recommendations, circumcision should no longer be considered a cosmetic procedure after the neonatal period. Instead, the current medical literature supports this procedure as medically necessary and appropriate for infants. Therefore, based on current evidence, circumcision is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested procedure 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 pediatrics with sub-specialty certification in pediatric critical care 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.