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

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees moderate deficits in receptive and expressive language skills.  Findings:  The physician reviewer found that the current medical evidence supports the medical necessity of the requested speech therapy in this patients case.  Per Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  This patient has moderate receptive and expressive language delay. These deficits are significantly impairing his ability to communicate effectively and function socially. All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that The documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patients post acute withdrawal syndrome were not at a level, which required 24 hours per day, seven days per week monitoring. The records document that her vital signs were stable. She was not a danger to herself or to others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. The patient was medically and psychiatrically stable to the extent that she did not need 24 hours per day, seven days per week monitoring.  There were no other significant symptoms that would interfere with her care such as mania or psychosis.  No new problems had arisen and medications were essentially unchanged.  Her clinical institute withdrawal assessment for alcohol was a six.  Relapse education and the development and solidification of coping skills against triggers could have been provided at a lower level of care and she could have been stepped down to partial hospitalization program. Therefore, the residential treatment center services were not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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

A 42-year-old female enrollee has requested Qsymia for treatment of her rheumatoid arthritis, asthma and obesity.  Findings:  The physician reviewer found that the requested medication, Qsymia, is a combination of phentermine and topiramate. The patients records support Qsymia as medically necessary for treatment of her obesity. The patient contributes her weight loss to the medication and she has been able to control her blood pressure without antihypertensive medication. However, her body mass index (BMI) is still over 30, thus additional treatment with the medication is indicated (Garvey, et al). A recent article has also cited the beneficial effects of this medication on hypertension (Engeli and Jordan). All told, the requested Qsymia is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested an ultralight wheelchair for the treatment of his T-10 paraplegia. Findings:  The physician reviewer found that this patient meets generally accepted medical necessity criteria (Medicare criteria) for a mobility assistive device (i.e., a manual wheelchair) as he has a mobility deficit that impairs his ability to perform mobility-related activities of daily living (MRADLs) within the home and this deficit cannot be ameliorated with a cane or walker because he is non-ambulatory. The patient is able to propel a manual wheelchair. He meets Medicare durable medical equipment (DME) criteria of medical necessity for an ultralight manual wheelchair, as it is necessary for treatment of his condition and is prescribed by his physician. The patients current wheelchair is inadequate to enable him to perform MRADLs within his home and to transport to work. Although the patient may not have current problems with his upper extremities, as a long-term paraplegic, it is necessary to prevent such deterioration through the use of an appropriate mobility device.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for magnetic resonance spectroscopy (MRS) of the brain. Arginase deficiency is an inborn error of metabolism. Manias and Peet described that MRS is a novel advanced imaging technique used as an adjunct to MRI to reveal complementary non-invasive information about the biochemical composition of imaged tissue. The authors noted that, Inherited metabolic disorders demonstrate accumulation of neurotoxic metabolites visible on MRS. The technique has proved to be useful in detecting early metabolic abnormalities prior to clinical or MRI changes in children with rare metabolic diseases. For these reasons, the requested MRS of the brain is 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 requested MRS of the brain is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewer 2 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in neurology with special qualification in child neurology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 6-liter portable oxygen tank. This patient is currently receiving supplemental at 6 liters per minute (6L/min) continuously via oxygen tanks. The requested portable concentrator delivers oxygen on-demand in pulses during early inspiration, but not continuously throughout the respiratory cycle. Pulse delivery systems are lightweight and portable, and can improve the quality of life for patients with chronic lung disease. However, pulse systems are not effective in all patients. Marti and colleagues reported on a cross-sectional study that showed exercise desaturation occurred in nearly 40% of patients with interstitial lung disease using pulse delivery systems. Given the advanced nature of this patients interstitial lung disease, a portable concentrator will not likely deliver adequate oxygen to meet his cardiopulmonary needs during the day. There is an absence of documentation that a pulse-based oxygen delivery device would be safe in this patient, and yield adequate blood oxygenation. All told, the requested 6-liter portable oxygen tank is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is 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 internal medicine with subspecialty certification in pulmonary disease 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 female enrollee requested intravenous infusions of Rocephin (ceftriaxone); and home health visits ancillary to the intravenous infusions for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. Despite treatment with ceftriaxone daily for three months there was no appreciable improvement after treatment which provides doubt to the diagnosis of neuroborreliosis. Further, there is a lack of evidence in the peer reviewed medical literature that prolonged or repeat courses of antibiotic are efficacious. In sum, the ceftriaxone was not medically necessary. Further the home health services associated with the administration and care of the patient for visits ancillary to the intravenous infusions were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested a power wheelchair for treatment of her cerebral palsy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The records forwarded for review indicate that the patient has fair to good strength in her limbs.  She is ambulatory in the home environment, but she has sustained falls.  The patients residence does not have wheelchair-accessible ingress/egress.  Her needs with respect to mobility-related activities of daily living in the home could be resolved with an assistive device such as a cane, walker or manual wheelchair.  A power mobility device is not medically necessary for this patient given that her mobility deficits in the home can be addressed by other means.  Ongoing exercise through ambulation aided with an appropriate assistive device would be expected to provide significant health benefits use over power wheelchair use.  All told, the requested power wheelchair is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female has requested referral to bariatric surgeon, Peter Crooks, MD for duodenal switch bariatric surgery for treatment of her obesity, diabetes mellitus, hypertension, hypercholesterolemia, and pain in the lower back, knees, ankles and feet.  Findings:  The physician reviewer found that based on review of the available records, this patient meets all of the standard criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guideline criteria. This patient is over 18 years of age, has a BMI that is greater than 50, has failed dietary efforts in the past, and has completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery. Consistent with these findings, the requested authorization and coverage for referral to bariatric surgeon, Peter Crooks, MD for duodenal switch bariatric surgery should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old male enrollee has requested laparoscopic Roux-en-Y gastric bypass for treatment of his obesity. Findings:  The physician reviewer found that given the patients BMI and comorbid conditions, the only viable option of controlling his obesity is surgical intervention. Non-surgical methods are unlikely to benefit this patient. Furthermore, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese (see studies by Adams, et al. and Bray). The requested surgery is medically indicated and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested percutaneous sclerotherapy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the literature reviewed regarding sclerotherapy in this clinical setting consists of small case series and case reports. The medical literature supports surgical excision as the standard of care for orbital dermoid cysts. Based upon a review of the peer-reviewed literature as well as the recommendations of the treating physician, sclerotherapy is not indicated for this patient. The standard of care as indicated by the literature for treatment of dermoid cysts is surgical. While sclerotherapy may prove to be effective in time for the treatment of young children with this condition, the paucity of data on the success of this treatment in this patient population precludes a recommendation to supports its use as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested services are 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:  One reviewer is board certified in ophthalmology and is actively practicing. Two reviewers are board certified in pediatrics with sub-specialty certification in critical care medicine 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: Upheld

A 61-year-old male enrollee requested periodic UroVysion (CPT 88120) for medical evaluation of his bladder cancer.  Findings:  Three physician reviewers found that periodic testing with UroVysion is not likely to be more effective for this patient than other available options. The peer-reviewed literature does not support the use of UroVysion in this clinical setting. UroVysion is a fluorescence in situ hybridization (FISH) assay that detects bladder cancer in urine specimens. At this time, cystoscopy and cytology, and possible biopsy, is medically indicated in this clinical setting regardless of the results of FISH testing. Therefore the requested services are not likely to be more beneficial for evaluation than standard diagnostic studies in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested coverage for treatment by a certified myofascial release specialist for treatment of the enrollees myofascial pain. Findings:  The physician reviewer found that myofascial trigger points are hyperirritable, palpable areas, usually within taut bands of skeletal muscle bellies, with characteristic referred pain patterns (Lavelle, et al). The precise underlying pathophysiology has yet to be fully determined (Mense; Giamberardino, et al). Typical treatments that are clinically used include spray and stretch, transcutaneous electrical stimulation, physical therapy, massage, local injection therapy, and dry needling. However, no clear marginal efficacy of one treatment over another has been demonstrated in the medical literature. In this patients case, no marginal analgesic, health, or functional benefit of myofascial release therapy performed by specialist therapy providers is anticipated over basic massage, standard physical therapy interventions, or basic palliative measures. Further, no significant, sustained benefit would be reasonably expected with the requested therapy over standard physical therapy care. Therefore, the requested specialized myofascial release therapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 29-year-old female enrollee has requested Botox injections for treatment of her headaches.  Findings:  Three physician reviewers found that the submitted documentation indicates that this patient has used beta blockers at therapeutic doses, anticonvulsants, antidepressants, and has tried Namenda, which is often used off-label for refractory migraine.  The records document the patient has 15 or more headaches a month lasting greater than six hours.  Her condition is confounded by chronic neck pain.  Given a long history of migraine which is consistent with chronic migraine, and documentation of previous trials of multiple standard therapies, there is adequate support for Botox injections in this setting.  Therefore, Botox injections were and are likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested electroconvulsive therapy (ECT) for treatment of her behavioral health problems. Findings:  The physician reviewer found that based upon the patients attitudes toward treatment and people in general, it appears there is significant underlying personality pathology which is not clearly amenable to treatment with ECT. Further evaluation is necessary to confirm the patients diagnoses. Moreover, it is not apparent that this patient has exhausted less invasive, known effective and available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested growth hormone (GH) therapy (Nutropin AQ) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that this patients projected adult height could approximate six feet according to the Greulich and Pyle Hand Atlas Table. However, the patients endocrinologists letter indicates an annual growth velocity of 1.2 cm, which is subnormal. The stimulation testing showed subnormal GH responses. The records indicate the patient is overweight. Relative obesity is also associated with blunted GH responses, especially in a patient who is insulin-resistant. Based on the evidence provided, this is a patient who has markedly delayed puberty who appears to be destined to reach a normal adult height (given the heights of his parents). The objective documentation does not does not provide confirmatory evidence of the stated low growth rate of 1.2 cm per year. In this case, there is no documented evidence over time of an abnormally low growth rate; a valid growth rate requires height measurements of six to twelve months in duration, and not over a lesser period of time. The submitted records in this patients case do not support the medical necessity of Nutropin AQ.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for 30 days of residential treatment center services or 14 days of inpatient hospitalization.At issue in this case is whether 30 days of residential treatment center services are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. If not, 14 days of inpatient hospitalization are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. 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, including minimizing the progression of that 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.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for 30 days for residential treatment center services.With regard to risk of harm, the records support a score of 3. In the last evaluation two weeks ago, the patient had passive suicidal ideation without intent or plan, resulting in a moderate risk for harm.In terms of function, the records support a score of 3. The patient has been primarily in treatment for the last few months. She has not been able to work and has issues with her relationships and fulfilling responsibilities.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested AcipHex DR 20mg tablets for treatment of her gastroesophageal reflux disease (GERD) and gastritis.  Findings:  The physician reviewer found that there is no scientific or empiric data available to demonstrate that AcipHex is medically necessary for treatment of this patients GERD and gastritis. Although the request forms note the patient has been treated with various PPIs, some patients require treatment with a second agent or a change in dosing. Given the limited records provided for review, there is inadequate documentation supporting the medical necessity of AcipHex in the treatment of this patients medical condition.