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

A 43-year-old female enrollee has requested psychotherapy four times a week for treatment of her behavioral health condition. Findings:  The physician reviewer found that according to American Psychiatric Association (APA) guidelines for the treatment of patients with major depression, the optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The APA notes that the following factors should be considered in determining the frequency of therapy: response and adherence to treatment, presence of a therapeutic alliance, and presence of suicidal behavior. APA treatment guidelines also indicate there are a number of treatment options for the treatment of major depression and while psychodynamic psychotherapy has been used in clinical practice for the treatment of patients with major depressive disorder, its efficacy for this diagnosis has not been adequately studied in controlled trials. A review conducted  by Wietersheim and Kessler regarding psychotherapy for patients with chronic inflammatory bowel disease (such as Crohns disease) notes that there are a variety of  beneficial interventions to consider with such patients including behavioral interventions, stress management, self-management and community support.In the case of this patient, the submitted documentation demonstrates the patient has moderate psychological symptoms with a diagnosis of major depressive disorder complicated by stress related to a medical diagnosis of Crohns disease. While psychotherapy was and is clinically indicated for this patient, the medical necessity for psychotherapy four times per week has not been established. The patients GAF score indicates moderate functional impairment as opposed to severe symptoms. Psychotherapy at a frequency of four times per week is reserved for patients with severe impairment. Given the level of functioning described in the submitted clinical documentation, psychotherapy twice weekly would have been reasonable and appropriate from the date in question onward. Continuation of psychotherapy at a frequency of two hours per week is clinically indicated and necessary going forward.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for growth hormone (GH). The submitted documentation supports that the requested medication is medically necessary. Federal Drug Administration and Pediatric Endocrine Society guidelines have approved the use of GH for children who meet the diagnosis of ISS. In this case, the patient has a short stature that meets the definition of ISS, as his height is below the accepted -2.25 standard deviation below the mean for age and sex. The patient has an estimated predicted adult height of 5 feet and 3 inches. This height is below normal for an adult male. The patient has an estimated adult height that is below the mid-parental target height of 5 feet 10 inches, and without treatment, he will not meet his genetic potential. Nutropin AQ Nuspin is an approved growth hormone medication for the treatment of ISS. Accordingly, the requested Nutropin AQ Nuspin 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 pediatrics, with subspecialty certification in pediatric endocrinology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old male enrollee has requested authorization and coverage for weekly individual therapy sessions with a psychologist or therapist and benzodiazepine. In the current medical literature, there is a lack of defined frequency or duration for the amount of psychotherapy required for each patient. It is generally accepted that patients in crisis require more frequent sessions than those who are stable. Studies reported that the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. Thus, the current literature supports an acute course of 12 sessions of weekly individual therapy sessions. However, benzodiazepines are not recommended for adolescents for the treatment of anxiety. Studies have not demonstrated that these medications are safe and effective for children and adolescents given the risks of possible addiction, developmental delay, and cognitive impairments. Given these findings, weekly psychotherapy for 12 sessions is medically necessary, while the requested benzodiazepine is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gelsyn injections x 3 to the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited. The enrollee is unable to have corticosteroid injections due to facial flushing. The osteoarthritis of the left knee is mild, and she is not a candidate for total knee arthroplasty. All told, the requested Gelsyn injections x 3 to the left knee are medically necessary for treatment of this patient.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 orthopedic 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: Urgent Care
Decision: Upheld

The parent of a 17-year-old female enrollee has requested  for emergency services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that the patient had a sore throat for four days which was worse initially than on the day that she presented in the emergency room.  There is conflicting evidence regarding her level of pain in the emergency room, but the physician clearly stated that the patients pain was described as mild by the patient and that she was in no acute distress. There was no respiratory distress noted and she did not have a fever. All told, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a wheelchair for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the requested wheelchair. Lennox-Gastaut syndrome is an epileptic encephalopathy with a diverse set of etiologies, all of which converge on a clinical phenotype that is characterized by profoundly impaired cognitive development, and the requirement for a variety of mobility assisted devices. In this case, the patient presents with Lennox-Gastaut syndrome with frequent seizures, including head drops and flexor spasms involving her head and arms. Hence the need for specialized wheelchairs, and other adaptive devices are indicated to foster mobility and prevent injury. In addition, patients with Lennox-Gastaut syndrome continue to grow and develop, both physically and mentally. Thus, modifying the patients current seat of the wheelchair does not provide a long-term solution as the patient continues to grow. All told, the requested wheelchair is medically necessary for this patient as it will likely improve her physical well-being, and increase mobility.  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 neurology with special qualification in child 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center (RTC) services for treatment of the enrollees anorexia nervosa. Findings: The physician reviewer found that based on the records provided for review, no aspect of this patients medication management, individual or group therapy required treatment at the RTC 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. The documentation including the intake evaluations and multiple progress notes throughout the course of treatment document the patients mild symptoms and denial of any risk of harm to herself or others. In the psychiatric progress note dated is noted that her mood is super happy and she continues to have ongoing panic attacks twice since admission. The physician was detoxing from alcohol, benzodiazepines, and opiates after reportedly drinking a pint of whiskey daily for six months. She noted she had been clean and sober for 17 days prior to admission and had been prescribed Xanax. The patient was tearful during the initial evaluation and discussed that she is struggling with bulimia and anorexia and is a laxative abuser. No suicidal or homicidal ideas were reported and no psychosis was reported. The patient continued to have regular flashbacks and PTSD symptoms. The patient was started on prazosin 1 mg nightly, Effexor 112.5 mg daily, gabapentin 600 mg three times daily, Vistaril 100 mg as needed for anxiety three times daily, and trazodone 100 mg three tablets nightly as needed for insomnia. In a nursing progress report was noted she was alert and oriented. On that date, her mood was of five out of 10 and anxiety was eight out of 10. In the psychological addendum, it was noted that she was not having any negative behaviors and she remained positive and hopeful towards recovery. She was attending 12 step meetings, and continued to take trazodone 300 mg nightly for sleep. All told, the patient did not require the supervision, support, and treatment provided at the RTC level of care through discharge as she could have been safely and adequately treated in a less restrictive treatment setting. Thus, the RTC services provided were not medically necessary for 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (Anser IFX, Anser IFX-measurement of serum infliximab (IFX) and antibodies to infliximab). The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees  Crohns disease.Findings While there has been debate around the optimal monitoring and management of children with inflammatory bowel disease treated with infliximab, current treatment guidelines published by the American Gastroenterological Association Institute in 2017 recommend monitoring of infliximab levels. In some published studies, these levels and the presence of drug antibodies have been cited as a factor associated with loss or lack of response to infliximab treatment. In this patient, the presence of antibodies and an undetectable drug level led to modifications in his management and he remains in remission. Given that drug level and antibody monitoring are recommended and that they have led to changes in patient management, these factors may be contributing to this patients remission. All told, the genetic testing (Anser IFX, Anser IFX-measurement of serum infliximab (IFX) and antibodies to infliximab) performed were likely to have been of greater benefit than the available standard methods of evaluating this patients medical condition.Final Result: All three reviewers determined 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:  All three reviewers are board certified in pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) procedure. TIF is an endoscopic procedure performed to create a full-thickness serosa-to-serosa plication. TIF can be performed in patients with typical GERD symptoms, no or low-grade erosive esophagitis, and either no hernia or a small hiatal hernia measuring less than 2 cm. This patient meets these criteria. However, the durability of TIF is less certain than that of standard available interventions. In a meta-analysis of five randomized trials and 13 prospective studies, proton pump inhibitor use after TIF increased over time. This patient has reported 80% symptom relief with use of Dexilant. Thus, the records do not demonstrate that the TIP procedure is likely to provide greater benefit than standard available therapies. Accordingly, the requested TIF with the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested TIF with the EsophyX device is not 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 TIF with the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical procedure (modified zero depth vaginoplasty in which the penile tissue is not resected or reshaped, but to include bilateral orchiectomy and shaping of scrotal skin into labia, and with no vaginal canal creation). The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) supports certain interventions for patients that can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Zero depth vaginoplasty, or vulvoplasty, is an increasingly common option for genital surgery in the treatment of patients with gender dysphoria. However, the WPATH SOC requires two mental health assessments to be considered for genital surgery. The records provided for review do not include documentation from providers that the requested surgery is a medically necessary procedure to address gender dysphoria in this patient. Therefore, the requested surgical procedure (modified zero depth vaginoplasty in which the penile tissue is not resected or reshaped, but to include bilateral orchiectomy and shaping of scrotal skin into labia, and with no vaginal canal creation) is not medically necessary for 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 with expertise in transgender health 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 62-year-old female enrollee has requested physical therapy  for treatment of her distal radius and ulnar fractures.  Findings:  The physician reviewer found that the patient sustained a cervical spine fracture, right forearm fractures and exacerbation of a pre-existing right rotator cuff injury due to a car accident two years ago. She was immobilized at the right elbow and forearm following surgery. She had some paresthesia in the distal right upper limb, but no apparent residual objective neurological deficits per neurosurgery note. As of the said date, the patient had regained significant right forearm supination (0-79 degrees), right forearm pronation (0-75 degrees), right wrist flexion (0-49 degrees) and right wrist extension (0-49 degrees). As of the date in question, the patient had essentially healed from her cervical spine surgery, with no pain symptoms and slight tightness and muscle spasms in the posterior cervical spine area on exam. Based on the above findings, as of the date in question, the patient was approximately four months post motor vehicle accident and had undergone sufficient therapy to be independent with a home exercise program for continuing to improve range of motion and strength at her cervical spine, shoulders and upper limbs. No significant benefit in health or functional outcomes would have been expected with ongoing therapy over an independent program as of the date in question forward. Further, there is no proven benefit of formal therapy interventions such as electrical stimulation and ultrasound in the setting of chronic musculoskeletal conditions related to the spine or upper limbs. Millar and colleagues noted in their case series that it was difficult to distinguish the effects of shoulder physiotherapy from the effects of time. According to Moffett and colleagues, the overall emphasis of physiotherapy needs to be self management and a return to normal activities. All told, the clinical and scientific evidence does not establish the medical necessity of the patients physical therapy from the dates in question.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a continuous glucose monitoring system (CGMS).A continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Over the last decade, continuous glucose monitoring systems have been demonstrated to be clinically valuable. A continuous glucose monitoring system can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Continuous glucose monitoring systems have been confirmed to be a safe modality, with high accuracy in glycemic values and a low complication rate. In this case, the patient presented with high A1C levels. However, the patients glycemic control has improved and her A1C had previously been above goal. Nevertheless, a CGMS is necessary to reduce the risk of future hypoglycemia and hyperglycemia. Therefore, the requested CGMS is medically necessary for treatment of the patients medical condition.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.