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

A female enrollee requested the surgical procedure, cervical C4 and C5 fusion for medical treatment of her flare up of cervical pain with left sided radiculopathy status post motor vehicle accident.   Findings:  The physician reviewer found that the patients records do not document an indication for the requested surgery such as unstable vertebral fracture, spinal dislocation, segmental instability, tumor or infection.  Moreover, there are no findings consistent with cervical radiculopathy with matching dermatomal and myotomal symptoms and findings, evidence of a myelopathy, pseudarthrosis, or evidence of failure of conservative therapy (Polston). All told, the requested surgical procedure, cervical C4 and C5 fusion is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 28-year-old super morbidly obese woman who has a body mass index (BMI) of 69. She apparently tried a short course of medically managed weight loss for 1.5 months but this was interrupted by pregnancy. She has comorbidities of hypertension, asthma, and joint pains. There is no documentation of psychiatric evaluation. The patient has requested authorization and coverage for weight loss surgery. The Health Plan has denied the request on the basis the requested procedure is not medically necessary.With a BMI of 69 and comorbid conditions such as hypertension, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not yet obtained psychological clearance for weight loss surgery. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for sleep studies. As noted in the medical literature, OSA is a condition caused by anatomical changes leading to obstruction of the upper airway during sleep. This patient underwent a three day sleep study. However, the testing was not performed in accordance with the standards established. Notably, the home sleep testing device used in this case was a Type IV HST unit which only measured one channel of respiration. The home sleep test unit in this case did not involve a respiratory effort sensor. This is below the minimum standards recently reaffirmed for the use of home sleep testing units. Furthermore, the current standard of practice indicates that one night of home sleep testing is sufficient to establish a diagnosis of OSA. All told, the sleep studies rendered on were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Taltz.Taltz has been approved by the U.S. Food and Drug Administration and is indicated for the treatment of moderate-to-severe psoriasis. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology-National Psoriasis Foundation (AAD-NPF), patients who have psoriasis affecting between 3-10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating provider with attention paid to the patients comorbidities. In this case, the patient has periumbilical psoriasis. This area is difficult to treat with topical medications. In this case, the records document a PASI score of 25, and treatment with Taltz has reportedly been effective. There is sufficient support for the requested medication in this clinical setting. Based on these factors, Taltz is medically necessary for the treatment of the patients medical condition.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 dermatology 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: A 28-year-old female enrollee has requested authorization and coverage for facet nerve blocks, bilateral L3-L4, bilateral L4-L5, and bilateral L5-S1for treatment of the enrollees lower back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. While this patient has some physical examination findings supporting facet joint syndrome, there is documentation of degenerative disc disease and radicular pain and radiculitis.  There is no documentation of medication trials, a home exercise program or the extent of physical therapy. The medical evidence does not support the requested services in this clinical setting.  Clinical practice guidelines which present an algorithm for the management of low back pain where there is a discogenic component, emphasize the treatment of the disc as the primary pain generator. In this case, conservative therapy has not been documented as suggested by the recent clinical practice guidelines of the American College of Physicians. All told, facet nerve blocks, bilateral L3-L4, bilateral L4-L5, and bilateral L5-S1 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electron beam computed tomography. In this case, the patient has significantly increased coronary risk. The American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary calcium quantification, advanced lipoprotein analysis, genetic testing, and homocysteine. While the results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of data from controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes over those achievable with treatment based on standard risk factor profiling and basic lipid analysis. Therefore, electron beam computed tomography is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested electron beam computed tomography is not 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 service is 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: Physician reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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

The patient is a 33-year-old male who has been diagnosed with bipolar depression and post-traumatic stress disorder. In an undated report, the patient reported symptoms of depressed mood, anxiety attacks, impulsivity, increased risky behavior, racing thoughts, excessive energy, erratic behavior, loss of interest, and constant worrying. The patient denied current suicidal ideation. He had a history of two prior suicide attempts. The patient has been treated with therapy, a four-day psychiatric hospitalization in April 2016, and medications that included Effexor, Seroquel, Wellbutrin, Zoloft, and Lamictal. In a letter dated 4/23/19, the provider noted the patient has had manic episodes. On 7/2/19, the patients Beck Depression Inventory score was 42. A Generalized Anxiety Disorder 7-item (GAD-7) score was 18, and a Patient Health Questionnaire-9 (PHQ-9) score was 21. The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether TMS services are medically necessary for the treatment of the patients medical condition. TMS therapy has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of major depressive disorder in adults who have not responded to antidepressant medications. The physician reviewer found that patients with bipolar affective disorder (BPAD) may have a severely depressed mood and other impairments seen in major depressive disorder (MDD), they also have episodes of mania. A clinical trial by Sampaio-Junior and colleagues found no statistically significant remission rates in the use of TMS for the treatment of bipolar disorder. In this case, the patient has had prior manic episodes and meets the criteria for BPAD. BPAD and MDD are seen as two distinct disorders with different treatment algorithms. The medical evidence does not support the requested services in this clinical setting. Therefore, TMS 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.
Appeal type: Medical Necessity
Decision: Overturned

A sixty-one year-old male with bipolar disorder is requesting authorization for continued acute inpatient psychiatric treatment.  Reviewers Findings:The reviewing physician found that there is sufficient evidence that a more extensive hospitalization was medically necessary.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a four-year-old male enrollee has requested for floortime therapy for treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that floortime therapy is a framework that includes working with a child at his or her developmental level through a variety of therapies to improve individual differences in sensory-motor, language, and social functioning, and supporting family and other learning relationships. It is meant to tailor caregivers and decisions interaction to one childs unique functional profile. While floortime seems to have promise, there are no independent, peer-reviewed published studies of floortimes effectiveness for children with autism. Therefore, there is no data to support floortime as a proven and effective therapy for the treatment of autism spectrum disorder. In addition, there are other proven therapies available to this patient. Because of this lack of evidence supporting the effectiveness of floortime therapy and the fact that there are other proven therapies available.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for UCSF500 Cancer Gene Panel genomic testing.Findings:  Two out of three physician reviewers found that new biologic and molecular therapies for the treatment of recurrent or metastatic endometrial carcinoma are being assessed in clinical trials. The National Comprehensive Cancer Network guidelines recommend the use of next generation sequencing or molecular profiling for patients with endometrial cancer. Molecular analysis can help classify difficult cases and provide future therapeutic targets. This patient has stage IVB disease which may progress following partial response to first-line therapy. The medical evidence supports the requested services in this clinical setting. Therefore, UCSF500 Cancer Gene Panel genomic testing is likely to be superior over other methods of evaluating this patient. 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Urgent Care
Decision: Upheld

A 24-year-old female enrollee has requested for an emergency room visit for treatment of her diarrhea, vomiting and abdominal pain. Findings:  The physician reviewer found that the patient was not dehydrated, and her blood pressure was stable. There was no blood. This is an example of acute gastrointestinal syndrome in an otherwise healthy female. This is a problem usually evaluated in a physicians office or urgent care center. It does not rise to the level requiring emergency care. There was no imminent threat to body, the pain was moderate, and the patient did not have a fever.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee requested a water circulating cold pad with pump for medical treatment of her medical condition.  Findings:  Three physician reviewers found that in this patients case, the requested equipment is not likely to be more effective than other treatment options.  The documentation submitted for review did not contain a clear rationale as to the need for a cryotherapy unit versus standard cold packs or pain relieving ointments.  There is a lack of evidence that the proposed treatment would be more beneficial for the patients noted condition than available standard therapy.  All told, the superior efficacy of the requested water circulating cold pad with pump has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for one-on-one speech therapy for 12 weeks at 30 minutes per session for treatment of the enrollees severe language delays. Findings: The physician reviewer found the review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Children with Down syndrome have more complex speech and language disorders. Children with Down syndrome may have frequent cluttering or stuttering. In addition, frequent problems with articulation and more unusual pronunciation problems often occur (Kent and Vorperian). Children diagnosed with childhood apraxia of speech often require daily one-on-one speech therapy (Tierney, et al). In this case, the patient has not been formally diagnosed with apraxia of speech, however he does have many signs of this disorder. He has made progress with treatment that is directed toward childhood apraxia of speech. Moreover, the school district provides group speech therapy which is not appropriate for this patient. Speech therapy in the group setting cannot address more complex oral motor problems such as childhood apraxia of speech or severe articulation problems from Down syndrome. Based on the clinical documentation provided for review, one-on-one speech therapy is clinically indicated for this patient. For the reasons stated, one-on-one speech therapy for 12 weeks at 30 minutes per session is medically necessary for treatment of the patients medical condition.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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested for continued psychiatric care in a locked residential treatment facility  for treatment of the enrollees major depressive disorder, severe, with psychotic features. Findings:  The physician reviewer found that current psychiatric practice aims to place patients in the least restrictive treatment setting that is likely to be effective. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, due to multiple factors and unique considerations, more intensive services may be necessary. As noted in the American Academy of Child and Adolescent Psychiatry Practice Parameter for depression: The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment. While residential programming should continue, approval of continued residential treatment for a 60-day period would be premature at this point in time. Due to the complexity of this case and the patients continued symptomatology, an additional 30 days of residential treatment services from the date of this decision is medically reasonable and necessary. The appropriateness of residential treatment services beyond 30 days will depend on the patients progress with therapy. As such, the patient should be re-evaluated at the end of the 30-day period for possible continuation of residential care if clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyosted 75 mg/0.2 mL. Findings:  The physician reviewer found that records provided for review support this patients diagnosis of hypogonadism. The patients laboratory evaluation shows normal testosterone levels while on therapy, normal prostate specific antigen (PSA) levels for prostate cancer screening, and normal complete blood count. Clinical documentation outlines the patients hypogonadal symptoms while off therapy and improvement while on therapy. The patient has experienced side effects with testosterone cypionate, and inadequate relief of symptoms with Clomid. The patient has requested continuation of testosterone replacement therapy with Xyosted, given his positive response to this therapy, instead of intramuscular testosterone cypionate. On review of the available documentation, Xyosted for this patient meets the American Urological Association (AUA) and Endocrine Society guidelines for the treatment of hypogonadism. For these reasons, the requested Xyosted 75 mg/0.2 mL is medically necessary for 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 board certified in urology 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.