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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 43 hours per month of direct applied behavioral analysis (ABA) therapy, 9.5 hours per month of supervision and two hours per month of parent training for treatment of the autism. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. According a study, ABA therapy started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. The patient has made some progress, but he has only mastered 44% of the functional skills for a child of his age. ABA therapy at the frequency recommended by his provider is clinically indicated for this patient. Therefore, 43 hours per month of direct ABA therapy, 9.5 hours per month of supervision and two hours per month of parent training are 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-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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic hysterectomy, CPT 58571. For women who have completed childbearing and have significant symptoms, and a desire for a definitive end to symptomatology, definitive therapy with a hysterectomy is appropriate under the standards of care. In this case, the patients prolonged abnormal bleeding has had a significant impact on her quality of life. The provider has counseled the patient regarding all treatment options available, including less aggressive hormone therapy or ablation versus a more aggressive but definitive total hysterectomy. Given the patients age, diagnostic work-up, and poor tolerance of hormones, a laparoscopic assisted vaginal hysterectomy is medically indicated as the only definitive treatment that will treat her abnormal bleeding. Therefore, laparoscopic hysterectomy, CPT 58571 is medically necessary for the treatment of his 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 obstetrics and gynecology 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 cervical disc replacement surgery. Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical disc replacement surgery.A review of the recent medical literature with respect to cervical replacement in hybrid surgery for multi-level degenerative disc disease, demonstrates favorable clinical outcomes at short- as well as long-term. Cervical disc arthroplasty has been demonstrated to be a safe and effective treatment modality for single-level cervical radiculopathy or myelopathy, and also for two contiguous levels and hybrid constructs. The advantages of cervical disc arthroplasty over an anterior cervical discectomy and fusion include motion preservation, decreased revision rate, improved patient comfort and satisfaction with the procedure, and lesser degree of adjacent level disease. Data from one clinical study reported superior results when compared to anterior cervical discectomy and fusion up to seven years of post-operative follow-up. This patient underwent two-level anterior cervical discectomy and fusion. He has adjacent segment disease. Surgery is indicated since the patient has failed conservative treatment. The better procedure is a motion preserving hybrid total disc replacement as recommended by the patients provider. For these reasons, the requested cervical disc replacement surgery is 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: Experimental/Investigational
Decision: Upheld

A 36-year-old female requested coverage for NeuroStar transcranial magnetic stimulation therapy provided over a one-month period for treatment of the enrollees major depressive disorder. Findings:  Three physician reviewers found that the patient has major depressive disorder.  A letter from the provider noted that medications such as Zoloft and Paxil did not yield a clinically significant response at therapeutic levels.  The patient endorsed irritability, hopelessness, increased levels of anxiety, excessive ruminations and difficulty completing tasks.  She has requested coverage for NeuroStar transcranial magnetic stimulation therapy.  In this patients case, the services at issue were not likely to have been more efficacious than other available treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation as an appropriate acute phase treatment option for patients who do not respond to medication therapy.  However, this patient has reportedly only been treated with two different antidepressants.  There is no information in the record to show that other first-line treatments have been tried.  The submitted documentation does not show that the selective serotonin reuptake inhibitors (SSRIs) have been augmented with medications such as Abilify or Seroquel, or with more traditional augmentation strategies, such as lithium or thyroid hormone.  There is also no evidence that the patient has been treated with any antidepressant of a class other than SSRIs.  Therefore, NeuroStar transcranial magnetic stimulation therapy provided during the timeframe in question was not likely to have been more effective than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary. An enrollee has requested authorization and coverage for ketamine infusion for treatment of the enrollees complex regional pain syndrome. Findings:  The physician reviewers found that the patient is diagnosed with complex regional pain syndrome (CRPS). The submitted records noted that the patient has tried several medications but these medications were not effective. The records reported physical therapy as an ineffective modality for treatment of her medical condition. She has history of right upper extremity and left lower extremity CRPS. She has had sympathetic blocks but developed blisters afterwards. The records indicated that she has had multiple procedures without any true efficacy. The patient has not tried ketamine intravenously. The patients provider would like to trial an infusion of ketamine. The Health Plan has denied coverage for ketamine infusion as investigational for the treatment of this patient. The superior efficacy of the requested ketamine infusion has not been established in this patients case. The documentation does not mention trial and failure of standard treatment options for this patient. The patients psychologist had requested therapy and the physical therapist felt desensitization therapy would be helpful. However, there are no progress notes that comment as to how these requested modalities were working for this patient or if they were performed. While there is evidence of medication failure, there is no clear documentation of failure of the psychologists or physical therapists treatment recommendations. For all these reasons, the requested ketamine infusion is not likely to be more beneficial for the treatment of this patient than other treatment options.  Final Result: All three reviewers determined the requested ted services are 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 reviewers number one, two, and three are board certified in anesthesiology and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided from 5/2/18 through 5/24/18. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services.Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder.In the case, admission records from 05/02/18 show no evidence of a psychiatric emergency medical condition. Although intoxicated, the admitting history and physical shows that the review of systems was unremarkable for any medical issues, demonstrating that the patient was medically stable. He was psychiatrically stable as well. Per his mental status exam, the patient denied suicidal/homicidal ideation (not a danger to self or others), was cognitively intact and well-groomed. He showed logical thought processes, good insight and judgment, with euthymic mood and full range affect (not gravely disabled). He did not require, nor did he receive, any type of stabilization or evaluation other than what was standardly performed on admission to detoxification/residential level of care. His CIWA's on admission and subsequent to admission showed a minimal-mild level of withdrawal symptoms which could have safely been managed at a lower level of care, especially had he been started on medication assisted treatment. The services at issue were not necessary for diagnosis or treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services from 5/2/18 through 5/24/18.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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: Overturned

The father of a 12-year-old male enrollee requested authorization and coverage of a referral to a dermatologist for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees eczematous dermatitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested for an additional 24 sessions of speech therapy (twice weekly) for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that Law and colleagues noted the efficacy of prolonged speech therapy for improving speech developmental articulation defects in children. Thus, applying this data to this specific patient shows that continued speech therapy has potential benefit. The report by Goorhuis-Brouwer and Knijff noted that speech therapy is effective in most intellectually normal children as well as children who are intellectually challenged.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom foot insoles. Healy and Chen note that plantar fasciitis is a common cause of heel pain, and treatments vary from stretching exercises to different surgical options. Custom orthotics are standard of care treatment to alleviate painful plantar fasciitis and are fabricated from customized molds of the patients feet. Custom orthotics manipulate and correct abnormal biomechanics of a patients foot, allowing for a reduction in pressure to the origin of the plantar fascia. In this case, the patient has a diagnosis of painful plantar fasciitis and has tried and failed other conservative treatments. Given that custom orthotics are standard of care for the treatment of plantar fasciitis, the requested equipment is medically indicated. Therefore, custom foot insoles are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in podiatry 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: The parent of an enrollee has requested authorization and coverage for genetic testing (whole exome and mitochondrial DNA sequencing). Findings:  The physician reviewer found that : the patient with seizures and history of hypoglycemia. The patient has also been diagnosed with hypotonia and developmental delays. She has had an extensive work-up, including metabolic testing, with no definitive answer. There is a likely pathogenic duplication of chromosome Xp11.3p11.23, which overlaps partially with a duplication Xp11.22p11.23 that causes intellectual disability, speech delay, electroencephalogram abnormalities and seizures. The patients parent has requested coverage genetic testing (whole exome and mitochondrial DNA sequencing). The Health Plan denied the requested services noting that the requested services are investigational for the evaluation of this patients medical condition. There is sufficient support in the medical literature for the requested services in this clinical setting. WES is a technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patients phenotype.  Clinical indications for WES are a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype.  The utility of WES for gene discovery (to identify the genetic cause of well-characterized specific phenotypes) has been demonstrated.  The utility of WES in the clinical arena is becoming clear, showing a diagnosis is made by exome sequencing in approximately 25% of patients referred for this testing. The evidence shows that a diagnosis can be made more expediently using newer genetic technologies such as exome sequencing rather than embarking upon a diagnostic odyssey that includes invasive procedures ). Moreover, there is evidence that exome sequencing results assist with management . For these reasons, genetic testing (whole exome and mitochondrial DNA sequencing) is likely to be more effective than other methods for evaluating this patients medical condition.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 overturnedCredentials/Qualifications: Physician reviewer1, 2 & 3 are board certified in pediatrics and genetics 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

A 46-year-old female enrollee has requested for a hysteroscopic myomectomy with simultaneous laparoscopic myomectomies for treatment of her uterine fibroids.  Findings:  The physician reviewer found that the advantages of laparoscopic myomectomy over abdominal myomectomy include less post-operative pain and recovery period, shorter hospitalization, and cosmetically smaller abdominal scars. Also reported are fewer post-operative adhesions peripheral to the site of surgery. However, laparoscopic myomectomy is not without limitation as it is associated with a longer operative time and requires advanced endoscopic skills. Further, laparoscopic removal of large myomas (greater than 8 cm) increases the risks of hemorrhage and possibility for conversion to laparotomy. As this patient is under the treatment of a skilled provider, the requested surgery is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injection for the left knee. The enrollee has post-traumatic patellofemoral arthrosis and chondromalacia of the left knee. She had multiple injuries and subsequent procedures to her left knee, including quadriceps tendon repair. She had persistent left knee pain associated with chronic regional pain syndrome (CRPS). After two trials of Orthovisc intra-articular knee injections, the enrollees orthopedist determined her persistent left knee pain was caused by a non-traumatic quadriceps tendon tear due to her multiple graft and cartilage reconstruction surgeries in the past. Thus, the enrollee underwent surgical repair of the left knee with open quadriceps reconstruction with hamstring autograft, and patellar and trochlear cartilage repair. In subsequent post-operative follow-up visits, the orthopedist indicates the enrollees pain significantly improved, allowing her to gradually wean off narcotics and engage in knee muscle strengthening. A subsequent note indicates the enrollee no longer required braces for ambulation. She did however have the expected limitations due to her multiple extension mechanism procedures.  Radiographs showed significant posttraumatic arthrosis due to the increased mobility around the area of the patella in light of her attenuated quadriceps mechanism.  The orthopedist noted this is best managed by a maintenance program with therapy and he prescribed viscosupplementation due to the chondral thinning at her young age. The routine use of Orthovisc to prevent early osteoarthritis of the knee is not supported by much of the medical literature.  However, a review of the literature does show there may be a small statistical improvement. In this case, there are no other options for pain relief and there is no literature to support in favor or against viscosupplementation in a unique case such as this.  In consideration of this enrollees young age, the fact that she has a very complicated left knee problem, with limited other options, and since she has had considerable sustained relief in the past from these injections, Orthovisc injection for the left knee is medically necessary to treat this enrollees medical condition. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: EE requested authorization and coverage for weight loss surgery consultation for gastric bypass. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case. Although this patient is morbidly obese and has a symptomatic ventral hernia that cannot be repaired without substantial weight loss, bariatric surgery has not been determined to be medically necessary. There is no dietary evaluation or psychological evaluation that has documented this patients compliance with necessary lifestyle changes and there is no evaluation of stability from substance abuse. The medical necessity cannot be determined without documentation of a thorough multidisciplinary evaluation. Therefore, the current medical evidence does not support the requested services in this clinical setting.  All told, the requested consultation for gastric bypass surgery is not medically indicated 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 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.