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

The patient is said to have had back, neck and shoulder pain prior to her breast reduction surgery. The record of conservative treatment attempts to resolve the patients symptoms is limited to anti-inflammatory medications and weight loss. The photocopies of photographs provided do not show severe breast hypertrophy.  The patients request for reimbursement was denied by the Health Plan based upon a determination that the reduction mammaplasty was not medically necessary.According to the pathology report, the actual breast reduction was small and unlikely to have had a significant impact on the patients symptoms.  Although the patient had the type of complaints characteristic of symptomatic macromastia, the photos do not show the severe breast hypertrophy typically seen. Symptomatic macromastia is a mechanical problem caused by the pulling forces exerted on the musculoskeletal system by heavy breasts. Although the efficacy of breast weight reduction as a treatment for musculoskeletal strain is well established, the medical literature provides absolutely no evidence that correction of breast ptosis without a significant reduction of breast weight is an effective treatment for musculoskeletal pain. The reduction of 90 grams from the right breast and 33 grams from the left breast is well below the 5th percentile on the Schnur table and would be considered a cosmetic mastopexy according to the Schnur guidelines. Regardless of the patients musculoskeletal symptoms, there is no scientific evidence that the removal of such a small volume of tissue would effectively resolve her complaints.  Based upon the information set forth above, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested inpatient mental health services for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the records provided for review indicate that the inpatient treatment was not medically necessary. The notes do not indicate the patient met medical necessity criteria for inpatient mental health services. No aspect of her medication management or therapy required the inpatient mental health level of care, and all treatment goals could reasonably have been met at a less restrictive, less intrusive level of care, such as outpatient care. In none of the documentation including the intake evaluations and multiple progress notes was there any note that would suggest ongoing inpatient level of care treatment was necessary or appropriate given the patients mild symptoms and denial of any risk of harm to herself or others. Very few medication management changes were made, and they were minor adjustments that could have been conducted in an outpatient setting. For these reasons, the requested inpatient mental health services were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 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

A 59-year-old male enrollee has requested Lidoderm 5% patch and Skelaxin 800mg for the treatment of his lower back pain. Findings:  The physician reviewer found that there are multiple generic muscle relaxants on the Health Plans formulary which were not tried by this patient; therefore, the use of Skelaxin was not warranted. In fact, the submitted records indicate Skelaxin was only minimally effective for the patient. Furthermore, the use of Lidoderm for low back pain is not within the standard of care and the scientific literature is limited to case series and open-label studies only.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for stroller repairs for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the patients stroller is the primary source of mobility that the patient uses. The patient is quadriplegic and has cerebral palsy. Thus, the use of the stroller is mandatory for proper transport of the patient for activities of daily living (ADLs) and for routine daily travel. Based on the review of the current medical literature, the stroller repairs provided were medically necessary for treatment of this patients medical condition. 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a seven-year-old female enrollee has requested authorization and coverage for Comprehensive Gait Analysis Testing (computerized gait analysis) for evaluation of the enrollees mobility. Findings:  Three physician reviewers found that computerized gait analysis is commonly used in the pre and postoperative assessment of children with cerebral palsy. It is not an investigational or experimental modality. It is a standard tool for evaluation of mobility and there is a wealth of literature supporting its use.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement and authorization and coverage for residential treatment center services. The enrollee has diagnoses of moderate recurrent major depressive disorder, combined presentation attention deficit hyperactivity disorder, intermittent explosive disorder, nicotine dependence, cannabis use disorder, and alcohol abuse. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was used in this review. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the enrollees score is 3, as he has no active suicidal or homicidal ideation, but he displays extreme distress and there is a history of suicidal/homicidal behavior. For functional status the enrollees score is 2, as the enrollee demonstrates significant improvement in function following a period of deterioration. For comorbidity the enrollees score is 2, due to the presence of transient, occasional, stress-related psychiatric symptoms that have no discernable impact on his presenting condition. For recovery environment level of stress, the enrollees score is 3, due to exposure to substance abuse and its effects. For recovery environment level of support, the enrollees score is 2, as the family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For resiliency and treatment history the enrollees score is 3, since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Also, developmental pressures and life changes have caused some deterioration in function. For acceptance and engagement the enrollees score is 2, as the enrollee has developed a positive therapeutic relationship with clinicians and other primary care givers. The enrollees composite CALOCUS score is 17, which correlates with high intensity community-based services, as provided at the intensive outpatient program (IOP) level.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 15-year-old female with mandibular retrognathic class II dental malocclusion and deep overbite. Additionally noted is macrogenia. The patient had pre-operative orthodontic treatment. She underwent bilateral mandibular ramus osteotomies for mandibular advancement and concurrent reduction genioplasty. The Health Plan has denied coverage for the reduction genioplasty on the basis it was not medically necessary for treatment of the patients condition.The submitted cephalometric analysis would indicate a mandibular advancement of approximately 4mm with minor clockwise rotation of the body of the mandible. Photographs and cephalometric analysis do not show evidence of lip incompetence and other functional deficits related to macrogenia. The reduction genioplasty likely improved the cosmetic result of the surgery, but there would not have been significant facial deformity if the genioplasty had not been performed. As such, the procedure at issue was cosmetic in nature and not medically warranted.Based upon the information set forth above, I have determined that the procedure at issue was 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 two-year-old male enrollee has requested for occupational therapy for treatment of the enrollee, who has a history of developmental delay and feeding difficulties. Findings:  The physician reviewer found that in the study by Feder and colleagues, children with a history of prematurity demonstrated significantly lower legibility of writing and slower speed scores compared to healthy children born at term.  Motor disabilities are also more common in children born prematurely.  Occupational therapy, with its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, is well-suited to affect positive change in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Freestyle Libre - continuous blood glucose monitor (CGM).Findings:  The physician reviewer found that A CGM system is one of several devices approved by the U.S. Food and Drug Administration (FDA) that record blood sugar levels at repeated intervals throughout the day and night. Olczuk and Priefer note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. Zheng and colleagues report that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. CGM systems have become a useful tool for real-time monitoring of blood glucose in clinical and public diabetes management settings, and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety and accuracy of CGM systems, the requested equipment is medically indicated. Therefore, Freestyle Libre  CGM is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for residential treatment for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of continued residential treatment level of care.  The patient did not have a comorbid psychiatric or medical condition that would have necessitated continuation of the residential treatment setting. He was motivated in his quest for sobriety. He had not been using substances every day. He had employment and safe housing available to him in the community along with engaged parents.  The patient had completed family week. He was looking forward to a family visit that Sunday.  Up to that point, he had completed three-and-a-half weeks of residentially-based treatment that included a full range of recovery services.  His anxiety was well-controlled.  Per the records, the patient had not received any previous chemical dependency treatment during the episode of illness.  He had no prior history of community programming, outpatient drug and alcohol counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. This is significant in this case for two reasons.  First, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that comprehensive, evidence-based services provided at a less restrictive treatment setting would have been insufficient or inadequate after a three-and-a-half week course of residential placement. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryoablation of bone and lymph node metastases (CPT 20983). Tumor ablative therapies for palliation of disease complications are within the standard of care for the treatment of symptoms related to metastatic malignancies. This approach includes cryoablation, which has well characterized treatment protocols, standard equipment and technical characteristics. Cryoablation has been demonstrated to provide a safe and effective treatment option for both soft tissue and bony lesions in this clinical setting. Use of cryotherapy has been effective for the palliation of skeletal metastases as well. This patient has nerve pain due to hepatocellular carcinoma with involvement of the right fourth rib at the junction with the sternum. His pain has been refractory to conservative management. Given the support in the medical literature, the requested cryoablation of bone and lymph node metastases (CPT 20983) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested cryoablation of bone and lymph node metastases (CPT 20983) is likely to be more beneficial for treatment 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 treatment 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 oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: An enrollee has requested authorization and coverage for intensive outpatient program (IOP) services. The submitted documentation fails to demonstrate the medical necessity of the requested services. Despite a relapse while socializing with friends, the patient successfully completed chemical dependency treatment services and was prescribed an anti-craving medication, naltrexone. Upon presentation, the patient had a reassuring mental status examination with no craving, intoxication, physical ailments, safety issues or home environment concerns.  There was no input from treating providers articulating the factors and barriers precluding effective treatment in a less restrictive setting while it was unclear if the patient had previously pursued standard therapies, such as exposure response prevention or cognitive behavioral therapy, both of which are commonly provided in an office-based setting. Further, previous clinical documentation indicated that the patient did not have a therapist and had not been attending Alcoholics Anonymous, which suggests that the patient was not fully engaged in active treatment at the time. Thus, the records do not demonstrate that comprehensive care, including psychiatric services, evidence-based psychotherapy, chemical dependency counseling and community-based/sponsor-supported programming, delivered in accordance with a multidisciplinary treatment plan in the outpatient setting would be unsafe or inadequate. Therefore, the requested IOP services are not medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female has requested Botox injections for treatment of her trigeminal neuralgia. Findings:  Two physician reviewers found that this patient has been diagnosed with trigeminal neuropathy and mixed headaches, which is a term frequently used for migraine and tension type features, which may represent chronic migraine. Research trials have confirmed the safety and efficacy of Botox for chronic migraine however studies have not confirmed the benefits for tension type headache or for episodic migraine. Studies of Botox treatment for trigeminal neuralgia are of small size, not well controlled nor blinded. Some have suggested potential benefit, but the literature notes need for well designed, randomized, controlled and blinded studies. The details of this patients prior preventive medication trials are not listed, but the provider notes the patient has been on a variety of anti-seizure medications with insufficient benefit for headache. Despite this notation, there is inadequate information regarding the patients treatment history such that the use of Botox in the management of her condition was appropriately denied as investigational.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for 16 weeks for treatment of his chronic hepatitis C virus genotype 2.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. This patient has FibroSure and laboratory testing consistent with cirrhosis. Per the AASLD/IDSA guidelines, patients with cirrhosis are high priority for therapy. Per guidelines, cirrhotic genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for 16 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. The guidelines reflect the FUSION trial, which showed higher efficacy with 16 rather than 12 weeks of treatment. For these reasons, the requested treatment with Sovaldi and ribavirin for 16 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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 patient has advanced hepatitis C-induced liver disease based on liver biopsy results. He failed daily interferon therapy in 1997, Intron A in 1998 and Pegasys in 2004. The patients provider has recommended the patient initiate treatment with Infergen and ribavirin. The Health Plan has denied authorization for the proposed therapy on the basis that it is not medically necessary.The use of Infergen and ribavirin in this clinical setting is medically appropriate and indicated. Infergen has been approved by the Food and Drug Administration for the treatment of patients who are non responsive to traditional hepatitis C therapy. The patient has failed all other available medications. As such, he is an appropriate candidate for the requested therapy. Accordingly, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.