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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for medical genetics counseling (CPT 96040). 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 medical genetics counseling (CPT 96040) is medically necessary for the treatment of the patients medical condition. Genetic counseling helps patients understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease. This process integrates the interpretation of family and medical histories to assess the chance of disease occurrence or recurrence. Pilarski reported that the perception of risk may have a broad impact on both psychological parameters (anxiety, worry and distress) and risk management behaviors (preventive measures such as surgery, health screening, and lifestyle changes) for those at risk. In this case, genetic counseling is medically necessary. A patients anxiety about a family members condition or misunderstanding of risk may raise additional questions and/or concerns that are readily addressed by a genetic counselor. The medical evidence supports the requested services in this clinical setting. Therefore, medical genetics counseling (CPT 96040) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 clinical genetics and genomics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested for a breast MRI for evaluation of her breast condition. Findings:  The physician reviewer found that this patient has an asymmetric density (not a mass) within the superior aspect of the right breast. As this abnormality was only noted on a single mammogram projection and was not visualized on ultrasound, biopsy of this abnormality is not possible.  In order to perform a biopsy, the lesion needs to be visualized in two separate projections on mammography, visualized on ultrasound, or physically palpable. A breast MRI can further evaluate the right breast to determine if there is a persistent suspicious lesion. This area can then be biopsied under MRI guidance.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female has requested coverage for bevacizumab (Avastin for the treatment of her recurrent multifocal atypical grade II meningioma.  Findings:  Three physician reviewers found that the patient has been treated in the last three years for multiple atypical meningiomas occurring at various sites in her central nervous system. Her treatment has consisted of multiple surgical resections, whole brain radiation, and stereotactic radiation. The patients neuro-oncologist noted that the patient continues to have recurrence and at this time the limits of local treatment, specifically with radiation, are being reached. The provider noted that systemic treatment is indicated and has recommended treatment with bevacizumab (Avastin), which she believes would be of benefit to the patient. The patient has a rare manifestation of a rare disease and her treating physicians have thus far provided her with standard treatment, entailing, to date, three craniotomies, and extensive radiation. Her history and a review of the pattern of her disease indicates that it is likely that she will continue to have recurrent tumors, and that continued local treatment with surgery and radiation will be limited, and potentially harmful.It is clear that a systemic approach is indicated. Bevacizumab has a proven efficacy in the treatment of glioblastoma multiforme. While such data does not exist for Grade II meningiomas, the rationale for its potential efficacy as provided by the patients neuro-oncologist, and the references she has provided, are compelling. In sum, this patient has failed standard treatment and treatment with bevacizumab is likely to be more beneficial for treatment of the patients condition than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested authorization and coverage for biofeedback therapy.  The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees pain in the feet.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the request for residential treatment services is not medically necessary for treatment of the patients medical condition. In reviewing the records of this case, partial hospitalization services provided previously were safe, appropriate and adequately addressing the patients needs. Thus, there is no evidence that the patient has failed a less restrictive treatment setting. Further, since there were no clinical assessments provided, making the patients current status unknown, it is not possible to assert that a higher level of care is indicated.  Therefore, residential treatment center services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested acne surgery (procedure code 10040) for treatment of her acne. Findings:  The physician reviewer found that this patient is requesting coverage for acne surgery to treat closed comedones on her face.  Her prior treatment has included topical steroid creams as well as topical retinoid creams to reduce inflammation.  The requested services are not medically indicated.  As noted in the literature, standard therapies for acne include topical antibiotics, topical antimicrobial therapies, oral antibiotics and topical or oral retinoids.  Acne surgery is not a standard first-line therapy and does not prevent the occurrence of new lesions.  All told, the requested acne surgery (procedure code 10040) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of her articulation disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has had articulation difficulties since the age of two. The patient is a product of a twin pregnancy and motor and speech milestones have been consistently at the lower limits of normal. This would suggest that neuronal cerebral development was congenitally impaired, which occurs at a higher frequency in twin pregnancies compared with single births. The patient has been recognized as having significant speech articulation problems by his second-grade teacher and his resource teacher. A formal speech evaluation indicated moderate articulation deficiencies and the patients articulation is below that expected of a five-year-old. Although recurrent otitis media with associated recurring hearing impairment can impede the development of speech, it is probable that this patients articulation deficit is congenital and related to delayed cerebral maturation. Thus, the patient has a medical condition that is congenital in its origin. The paper by Goorhuis-Brouwer and Kniff reports that speech therapy is highly effective for the treatment of articulation disorders in patients with specific language impediment. The paper by Law and colleagues is a meta-analysis of 13 published reports over 25 years that notes the efficacy of speech therapy in improving speech development articulation defects in children. These articles relate that speech therapy is effective for the treatment of articulation defects. This patient has a congenital disorder that is readily treatable by speech therapy. Speech therapy is medically appropriate and indicated for the treatment of this patients articulation defect.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee requested psychiatric residential treatment level of care for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that, per the medical records, initial discharge would have been premature as the patient was still engaged in active treatment that was reasonably expected to improve his condition and prevent a more serious episode of illness.  In sum, the services consisted of evidence-based treatment and family involvement aimed at facilitating a seamless discharge to a less restrictive setting.  Subsequently, the patient had made significant improvement and demonstrated the consolidation of treatment gains needed to succeed in a less restrictive setting.  All told, initial psychiatric residential treatment level of care was medically necessary, while the records fail to demonstrate the medical necessity of subsequent psychiatric residential treatment level of care.  I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 23-year-old female enrollee has requested an implantable cardioverter defibrillator for treatment of her long QT syndrome and Class I mutation for long QT syndrome.  Findings:  Three physician reviewers found that in this patients clinical circumstance, even though she has not had syncope or sudden cardiac death, prophylactic ICD placement is appropriate due to the high risk of developing such an event based on her strong family history and identified gene mutation. Current guidelines endorsed by several national organizations also consider a prophylactic ICD placement reasonable in this setting. Specifically, the guidelines state that in patients with prolonged QT the use of the ICD for primary prevention of sudden cardiac death may be considered when there is a strong family history of sudden cardiac death or when compliance or intolerance to drugs is a concern (Epstein, et al). Other studies also support the use of primary prevention ICD devices in high-risk patients with a strong family history of sudden cardiac death and the same deleterious gene mutation as the proband identified in this patient (Zareba, et al; Monnig, et al). All told, the requested ICD is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested continued skilled nursing care for treatment of the enrollees cutis-marmorata telangiectatica congenita.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  This patient has multiple medical problems affecting his health and well-being.  While the parent has some skills needed to help care for this patient, continued skilled nursing care is medically appropriate.  This patient requires constant vigilance because of the risk of hydrocephalus and brainstem compression, aggressive respiratory care because of the risk of aspiration pneumonia, careful feeding because of the risk of aspiration, and prompt recognition and treatment of breakthrough seizures.  Such interventions require the clinical judgment, experience, and expertise of skilled nursing personnel, and cannot be provided at a lower level of care.  All told, the requested continued skilled nursing care is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 29-year-old female with thoracic outlet syndrome. She had tried physical therapy along with a home therapy program. The Health Plan has denied authorization for continued physical therapy on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The requested therapy is not medically indicated for treatment of the patients medical condition. There is no evidence the patient requires continued supervised therapy. The patient should be able to obtain benefit from a home exercise program. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation of uterine fibroids for treatment of her medical condition.  Findings: Three physician reviewers found that there are a number of non-surgical and surgical treatments for heavy periods and fibroids, including nonsteroidal anti-inflammatory drugs, progestins, oral contraceptives, Lupron, uterine artery embolization, minimally-invasive surgery such as laparoscopic myomectomy, and abdominal myomectomy or hysterectomy, which can also be done in a minimally-invasive fashion (mini-laparotomy).  Although this procedure may prove to be a good option for some patients with fibroids in the future, there is insufficient evidence available at this time to conclude that it is more beneficial than other available treatments.  Thus, radiofrequency ablation of uterine fibroids was not likely to have been more effective than other treatment alternatives. Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers are board certified in obstetrics and gynecology 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Xeljanz 5 mg tablets twice a day. The Health Plan has denied this request indicating that the requested medication regimen is considered investigational for treatment of the patients alopecia universalis. Findings: Three physician reviewers found that there is sufficient support for the requested medication regimen in this patients case. Systemic therapies are occasionally used for severe alopecia areata. A high likelihood of relapse, limited efficacy data, and the potential adverse effects of these drugs limit their use to refractory cases. The results of trials with standard therapies, such as glucocorticoids, sulfasalazine, azathioprine, and phototherapy, show poor rates of regrowth and are often limited by side effects. Researchers performed a retrospective study of 90 patients with alopecia universalis who were treated with tofacitinib (Xeljanz). The researchers noted 77% of patients with duration of current episode of disease of ten years or less achieved a clinical response. Thus, Xeljanz 5 mg tablets twice a day is likely to be more effective than other available treatment options.Final Result: The reviewers determined that the requested medication regimen is 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 dermatology 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: Overturned

An 18-year-old female enrollee has requested for a five-day-a-week, eight-hour-a-day intensive outpatient program (IOP for treatment of her eating disorder. Findings:  The physician reviewer found that the patients condition is severe and she regressed to a life threatening state prior to entering the residential program. The more intensive local IOP (five days a week, eight hours per day) is comparable to the  intensity of care provided in a partial hospital program. The patients history and the family dynamics strongly suggest that she needs this level of care and frequency of encounters. Family participation is also essential to successful treatment at the requested level of care. A family session involving the twin sister, mother and father (and any other family members) should occur at least one time per week for the duration of the IOP. If the family is not willing to participate in this requirement, the potential benefit of the IOP cannot be fully realized. The familys on-going commitment to weekly therapy is a reasonable prerequisite to initial authorization and continuing authorization for treatment in the non-Plan, five-day-a-week, eight-hour-a-day IOP.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested Lo Loestrin Fe for treatment of the enrollees endometriosis and growth of ovarian cysts.   Findings:  The physician reviewer found that although birth control pills are indicated as the first-line use in the medical management of endometriosis, the specific use of Lo Loestrin Fe is not clinically indicated at this time. There is a lack of evidence in the medical literature that supports the benefits in treatment goals of amenorrhea and reduction in pain with Lo Loestrin Fe compared to other low dose monophasic pills. That being the case, it is medically reasonable and appropriate for the patient to trial another pill currently on formulary. Furthermore, in a letter from the patients parent she states that the patient is at higher risk given her familial history of breast cancer. However, the medical records show that BRCA testing was performed and was noted to be negative. In sum, based on the medical records submitted for review and the medical literature cited above, the requested medication is not medically necessary at this time. Therefore, the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld

A 29-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patients symptoms were sustained 17 days prior to her visit. She had been evaluated for her symptoms on two separate occasions since then and was diagnosed with musculoskeletal pain. She had been prescribed both narcotic pain medication and a muscle relaxer. There had been no recent change in the patients condition, no new trauma, and no new neurologic symptoms. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. 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 her health in this circumstance.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested skilled nursing facility care for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Spinal decompressive surgery is an intervention to be considered in the setting of spinal stenosis failing conservative management.  After decompressive surgery, activity and exercise is encouraged, but there is no clear evidence of benefit or need for long-term supervision of exercises in a formal setting.  In this case, the patient underwent lumbosacral decompression and fusion surgery for intractable pain and radicular symptoms.  He was transferred to a skilled nursing facility on the specified date.  As of the specified date, the patient progressed sufficiently to the point that further care, including any ongoing physical therapy, can be provided in the home with custodial level supervision, followed by rehabilitation services in the outpatient setting.  There are no documented skilled nursing or medical issues requiring further skilled nursing care.  No marginally significant improvement in health or functional outcomes would be expected with the services at issue.  All told, skilled nursing facility care from the specified date forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested L4-5 total disc arthroplasty with ProDisc-L for treatment of his back pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other treatment options.  This patient has a history of low back pain and bilateral lower extremity pain.  Diagnostic studies demonstrate degenerative disc disease, most severe at L4-5 level with findings of a large disc protrusion along with moderate facet arthropathy and a congenitally small spinal canal which contributed to severe encroachment of the lateral recesses bilaterally and a moderate to severe degree of secondary central stenosis.  The current medical evidence has not established the superior efficacy of the requested services in this clinical setting.  Per the medical literature, the superior effectiveness of arthroplasty over fusion has not been demonstrated, and additional long-term studies are needed.  All told, the requested L4-5 total disc arthroplasty with ProDisc-L is not likely to be more efficacious than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

A fifty-three year-old female with a history of constipation and recent fecal incontinence is requesting coverage of a colonic motility study and biofeedback therapy.  Reviewers Findings:After reviewing the requested procedures 2 out of 3 physicians found that the colonic motility study was necessary, and 2 out of 3 physicians found that the biofeedback was not necessary.  The reviewers found that the Health Plan denial should be partially overturned.