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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for daily Klonopin 1 mg, two pills in the morning and Klonopin 1 mg, 1.5 pills in the evening for treatment of her posttraumatic stress disorder and attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that this transgender female is diagnosed with bipolar disorder, depression, severe without psychotic features, posttraumatic stress disorder, anxiety, and attention deficit hyperactivity disorder. The patient suffers from insomnia and reportedly neurocognitive difficulties. The provider notes cluster B traits. Her medical diagnoses include peptic ulcer disease, cardiac arrhythmias, and migraines.  She showed multidimensional hallucinations, and reported nightmares and flashbacks.  It was at that time that she was placed on Klonopin 1 mg two per day (BID).  Since this time, she has been on Risperdal, Ativan, and trazodone. Latuda was added later. It is unclear when this was discontinued.  She was on Adderall which was subsequently changed to Concerta.  She was on Trileptal, which was discontinued, and she reported feeling more alert. Klonopin was reduced to 1 pill in the morning and 2 pills in the evening.  Buspar was added.  The patient reported low energy and feeling down. Her mood was positive, she presented as well-groomed and stylish.  She noted that she has fractionally reduced the hydroxyzine and Klonopin. The patient has requested coverage for daily Klonopin 1 mg, two pills in the morning and Klonopin 1 mg, 1.5 pills in the evening. The patients documentation does not support the requested increase of Klonopin dosing. Symptoms reported do not support the need for coverage of 3 12 tablets per day (3 12 mg a day). The provider does not show documentation that the dose was increasing by small amounts to manage symptoms or decrease side effects/slowly wean off.  Moreover, there was no evidence that the patient was a rapid metabolizer and therefore required a higher dose of this agent.  The requested increase of Klonopin is not supported by the submitted records. Final Result: The reviewer determined that the requested medication dosage 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 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

The parent of a 16-year-old female enrollee has requested a cardio-thoracic specialist for evaluation of the enrollees thoracic pain. Findings:  The physician reviewer found that there is no medical literature that supports the proposition that this patients diagnoses of arthritis, mild scoliosis, and disc bulging require evaluation by a cardio-thoracic specialist. The patients diagnoses and MRI/x-ray findings do not reveal any information that would necessitate evaluation and/or treatment by a cardio-thoracic surgeon. The patients chest MRI revealed an area of incomplete fusion within her sternum. This finding probably reflects the patients young age. In any event, this patients situation is not one in which referral to a cardio-thoracic specialist would provide clinically useful information.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy, including augmented alternative communication (AAC) therapy and feeding therapy. As noted in the medical literature, 1p36 deletion syndrome is characterized by intellectual disability, seizures, feeding difficulties, congenital heart disease, ophthalmologic abnormalities, and skeletal abnormalities as well as hearing loss. In addition, speech and language delays in 1p36 deletion syndrome are common, with up to 40% of patients reported to have complex speech difficulties. One study reported that patients with 1p36 deletion syndrome greatly benefit from enrollment in a personalized rehabilitation program with attention to motor development, cognition, communication, and social skills. Given that the age of verbal speech onset is significantly delayed, progress is often slow and long-term speech therapy is recommended (study). Since starting speech therapy in 2014, this patient has improved from non-verbal to vocal, and is using her voice to gain attention and demonstrate desires as well as reject objects and activities. Overall, the patients speech therapy records indicate slow, steady progress, which is typical in this condition. Given the presence of feeding difficulties in 1p36 deletion syndrome, feeding therapy with attention to oral motor skills is also appropriate. Special feeding techniques or devices can be used for feeding a hypotonic patient without a cleft palate or those with an unrepaired cleft palate (study). Moreover, the use of AAC technology is appropriate in this case. According to Luke, speech-generating devices (SGD), as one method of AAC, can effectively enhance the communicative and linguistic development of children with severe childhood apraxia of speech. All told, the requested individual speech therapy services, including AAC therapy, and feeding therapy services are medically necessary for treatment of this 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 certifications in neurodevelopmental behavioral pediatrics and genetics 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 35-year-old female enrollee has requested consultation and treatment with a neurologist that specializes in autonomic neuropathy for the treatment of her autonomic neuropathy. Findings:  The physician reviewer found that the submitted clinical evidence does not support the need for further neurologic evaluation with a specialist in autonomic neuropathy. The records provided indicate that the patient has had vague and continuous dizziness for years. Mild dysautonomia has been diagnosed clinically, supported by tilt table test results. Extensive testing has otherwise been unrevealing. Depression has been diagnosed, and the patient has not been responsive to standard therapies. A psychiatric evaluation would be more appropriate in this setting than further neurologic testing or consultation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for individual speech therapy and occupational therapy for treatment of the enrollees autism spectrum disorder, attention deficit hyperactivity disorder (ADHD) and generalized anxiety disorder.  Findings:  The physician reviewer found that based on the out-of-Plan evaluation, the patient was diagnosed with developmental coordination disorder and was also found to have significant delays in self-help skills as measured on the Vineland Adaptive Behavior Scales. Occupational therapy targets self-help skills, and is therefore clinically indicated to ensure the highest level of future independence for the patient. Moreover, occupational therapy is medically necessary to promote the development of self-care skills such as dressing, manipulating fasteners, using utensils, personal hygiene along with academic skills such as cutting with scissors and writing. However, speech therapy is not medically necessary, given the patient has average receptive and expressive skills as measured during two separate evaluations. In this clinical setting, social skills group speech therapy is likely to be more appropriate intervention for the patient at this time. Based on the documentation submitted for review, individual speech therapy has not been established as medically necessary for treatment of the 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 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: Upheld

A 63-year-old male  has requested  a somnoplasty procedure for treatment of his obstructive sleep apnea and snoring.  Findings:  The physician reviewer found that the patient has had a previous radiofrequency procedure on the palate using the coblator device. The requested somnoplasty device uses the same radiofrequency technology as the coblation approach (Boudewyns and Van De Heyning). A study comparing the two techniques reported that there was no difference in the effectiveness of the devices (Blumen, et al). Since this patient has already undergone a radiofrequency procedure for the soft palate, a procedure with the somnoplasty device has not been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollee's autism spectrum disorder. Findings:  The physician reviewer found that overall, children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with patients on the spectrum, handling the myriad of communication challenges that they face, are the most appropriate providers of this type of care. Deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted the better chance the patient has for developing adequate skills to function in the community. This patient exhibits severe delays in expressive and receptive language, thus speech therapy is therefore medically necessary and appropriate at the frequency requested. In addition, deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children, and may lead to difficulties establishing relationships and navigating the occupations of adulthood. Case-Smith and Arbesman noted that, Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. Further noted is the import of therapy focusing on the development of motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information. For these reasons, OT is well suited to affect positive change in children with ASD. As this patient exhibits significant difficulties with processing sensory information as well as difficulty with fine motor skills, motor planning, and self-help skills, OT is medically necessary and appropriate for this patient, at the frequency requested.
Appeal type: Urgent Care
Decision: Upheld

A 22-year-old male enrollee has requested emergency services for treatment of his broken right clavicle.  Findings:  The physician reviewer found that based upon the evidence provided, a prudent layperson would not have sought immediate surgical intervention in this situation. The patient was promptly seen and appropriate immediate medical attention took place following the injury, i.e., x-ray examination to accurately diagnosis the patients condition, pain medication and adjustment in pain medication and the use of a sling. There was no evidence to lead a prudent layperson to believe that immediate surgery or surgery as early as the date indicated was necessary to address a serious medical threat. For the reasons set forth above, the patients symptoms did not meet prudent layperson criteria for emergency care on the date indicated. A prudent layperson in the patients circumstances would not reasonably expect the absence of immediate surgical intervention to jeopardize his or her health.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 42-year-old woman with a five-year history of right scapula pain. In addition, a review of the record indicates the patient experiences frequent headaches. The patient has requested authorization for Botox injections. The Health Plan has denied this request indicating that the requested injections are considered experimental.Use of Botox for headaches associated with cervical dystonia is an investigational application. There is no demonstrated efficacy of Botox for treatment of the patients condition. Until the FDA approves Botox for this indication, other treatment modalities are more appropriate. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 42-year-old woman with a history of a cervical and shoulder musculoligamentous strain resulting in cervicogenic headaches. The submitted records reveal a cervical disc bulge at C5-6, but not a ruptured disc. One of the patients treatment modalities has consisted of trigger point injections, which have provided some degree of relief. In addition, Neurontin has been prescribed. The patient has requested authorization for Botox therapy. The Health Plan has denied her request.The efficacy of Botox therapy for treatment of the patients condition has not been established. There is not sufficient data to demonstrate that Botox will help alleviate the patients symptoms. Repeated trigger point injections, combined with spasmolytic agents and massage are more likely to benefit the patient than Botox therapy. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 42-year-old woman with a history of a cervical and shoulder musculoligamentous strain resulting in cervicogenic headaches. The submitted records reveal a cervical disc bulge at C5-6, but not a ruptured disc. One of the patients treatment modalities has consisted of trigger point injections, which have provided some degree of relief. In addition, Neurontin has been prescribed. The patient has requested authorization for Botox therapy. The Health Plan has denied her request.The efficacy of Botox therapy for treatment of the patients condition has not been established. There is not sufficient data to demonstrate that Botox will help alleviate the patients symptoms. Repeated trigger point injections, combined with spasmolytic agents and massage are more likely to benefit the patient than Botox therapy. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee, who was involved in an accident, which resulted in a right femur fracture and left tibial plateau fracture, has requested authorization for knee surgery.  Findings:  The physician reviewer found that the patients left tibial fracture was approximately three weeks old and clearly appeared to be healing. Two orthopedic surgeons reviewed the most recent studies and found the fracture to be well aligned and not in need of repair. Surgical intervention would not guarantee the most optimal result. While surgery may have been considered at the time the femur was rodded or soon after the date of injury, it was not indicated at that time. If the fracture displaced, surgical intervention would then be required. However, based on the evidence available at the time, surgical intervention was not clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Physical examination revealed that the patients breasts were without masses. The patient underwent a mammogram, and the results were negative for any suspicious abnormalities. The patients breast tissue was noted to be dense. In the independent medical review application, the patient reported she has a family history of breast cancer. The patient has requested reimbursement for bilateral digital breast tomosynthesis and prospective authorization and coverage for yearly bilateral digital breast tomosynthesis. The Health Plan denied the request and reported the services at issue were not and are not medically necessary for the evaluation of this patient. At issue in this case is whether bilateral digital breast tomosynthesis and prospective yearly bilateral digital breast tomosynthesis was and/or is medically necessary for the evaluation of the patients medical condition. Current medical evidence supports the services at issue in this clinical setting. Helvie reported, While nearly all cancers will be apparent in fatty breasts, only half will be visible in extremely dense breast. This results, at least in large part, from the masking or camouflaging of noncalcified cancers by surrounding dense tissue. The author also noted digital breast tomosynthesis mammography would allow visualization of cancers not apparent by conventional mammography thus improving sensitivity. Friedewald and colleagues reported that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in the cancer detection rate. In this case, the patient has dense breast tissue and a family history of breast cancer. The medical evidence supports the services at issue in this clinical setting. Therefore, bilateral digital breast tomosynthesis and prospective yearly bilateral digital breast tomosynthesis was and is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service was and is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 16-year-old male enrollee has requested Humatrope (12 mg cartridge) for treatment of the enrollees growth hormone deficiency and hypoglycemia.  Findings:  The physician reviewer found that this patient meets standard criteria for GH deficiency, and continuation of therapy is medically necessary even beyond the time of epiphyseal fusion to prevent hypoglycemia. The patient presented with short stature during early childhood, hypoglycemia, and low growth factors. He has had an excellent response to GH therapy and resumption of hypoglycemia as well as drop in growth factors during times when therapy has been suspended. If therapy were to be discontinued, the patient would be at risk for life-threatening complications of acute hypoglycemia, including seizures, and loss of consciousness. The insulin antagonistic actions of GH are important in preventing hypoglycemia and omission of treatment may precipitate hypoglycemic events. All told, continued use of GH therapy with Humatrope (12 mg cartridge) is medically necessary for treatment of this patients medical conditions.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old male who presented to his urologist in April 2003 with a one-year history of difficulty obtaining a full penile erection and of maintaining an erection, along with decreased libido. He was treated with Viagra and in August 2004 reported that it caused heartburn and was only effective half the time it was used. In October 2004 the patient underwent a urology consultation. The patient obtained a less than 50% erection with intracavernosal injection and this was reported to be about the same type of reaction that he achieves with Cialis. Sonography of the penile artery demonstrated a small right arterial inflow with crossover to the left and no distal flow past the crossed over site. The patient was diagnosed with erectile dysfunction most likely due to poor arterial inflow. His provider recommended treatment with Cialis and that he be evaluated for potential hypercholesterolemia. In March 2005 the patient was reported to be doing well with Cialis and wished to continue treatment with the medication. The Health Plan has denied authorization for Cialis on the basis that it is not medically necessary for treatment of the patients condition.The patient has erectile dysfunction, the causation of which has been determined sonographically to be penile arterial disease. The patients condition has responded satisfactorily to treatment with oral Cialis, having failed treatment with Viagra and Levitra. The patient meets medical necessity criteria for authorization of Cialis. Continued use of the drug is medically reasonable and appropriate and should be authorized. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.