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

The parent of a two-year-old male has requested for speech therapy for treatment of the enrollees developmental disorder with speech delay. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. These authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  The authors reported that language-delayed children have shown more behavior problems and impaired psychosocial adjustment.  Thus, speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties. These authors concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has significant delays in receptive and expressive speech/language skills that negatively impact his ability to express his needs and interact with peers and adults. Objective testing has demonstrated language comprehension functioning at the 18-month to 24-month level and language expression functioning at the 12-month to 15-month level. The medical literature supports therapeutic intervention for children such as this patient to improve communication skills.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for physical therapy. Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine/gross motor skills and processing of sensory and motor information are also common. Many approaches have been used to facilitate development of adequate communication and interpersonal skills in children with autism. Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy. Deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children. Physical therapy, with its focus on gross motor skills, ambulation, balance, strength, and coordination, is ideal to facilitate development of a normal gait pattern in children with deficits in these areas. At the only formal physical therapy assessment performed, this patient was noted to have weaknesses in stationary standing, dynamic balance, and walking. Based on the submitted records, the requested services are medically necessary. Therefore, the requested physical therapy is medically necessary for the 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 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

The patient is a 49-year old male with right hip and lower back pain. He has tried Motrin for pain control with only mild relief and gastrointestinal (GI) upset. The patient reports a recent trial of Celebrex was very effective. He has requested authorization for the medication, which has been denied by the Health Plan on the basis that it is not medically necessary.Celebrex, a COX-2 selective NSAID, has not been proven to be more efficacious than other NSAIDs for pain relief. There are a number of NSAIDs available, and the submitted medical records do not support the need for treatment with Celebrex. Since Motrin caused GI upset, a trial of a generic NSAID, such as Naprosyn, along with a proton pump inhibitor would be a reasonable next step. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested chiropractic services for medical  treatment of her lumbar sprain.  Findings:  The physician reviewer found that  according to the evidence based literature, this treatment is not indicated for this patients cervicalgia, muscle spasm, lumbago, spondylolisthesis or lumbar sprain.  In addition, the patients response to treatment has not been positive overall and the provider did not include documentation to substantiate the need for ongoing treatment.  Given the lack of documentation as required by the Council on Chiropractic Guidelines and Practice Parameters, chiropractic services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  individual speech and language therapy at a frequency of two hours per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in this patients case, the requested individual speech and language therapy at a frequency of two hours per week is medically necessary.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.   The authors concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  This patient has receptive and expressive language deficits and articulation deficits that negatively impact her ability to achieve age-appropriate functional speech and language skills. Studies have shown that speech and language therapy can result in significant improvement in such children. While she has made some improvement with weekly therapy, individual speech and language therapy at a frequency of two hours per week is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested biofeedback treatment for treatment of her fibromyalgia. Findings:  Three physician reviewers found that the review of the medical literature shows a lack of evidence demonstrating that biofeedback is efficacious in the treatment of fibromyalgia. In a meta-analysis of EMG-biofeedback [EMG-BFB] and EEG-biofeedback in the treatment of fibromyalgia, Glombiewski and colleagues state that the long-term effects of EMG-BFB on pain intensity are unclear due to the small number of studies that included follow-up assessments. Further, a randomized clinical trial comparing fitness training versus biofeedback in the treatment of fibromyalgia showed that neither treatment had clear beneficial effects on objective or subjective patient outcomes in patients with [fibromyalgia]. (Bolwijn, et al.) In sum, there is insufficient scientific data to support the contention that biofeedback is likely to be of greater benefit in this setting than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 19-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that although acute hospitalization was initially indicated for this patient whose impairment encompassed the full-range of the bio-psycho-social-cultural model of conceptualization, as of the date indicated the medical record does not substantiate the need for continued inpatient psychiatric level of care. Despite requiring frequent redirection, the patient was not aggressive or violent in the milieu.  He did well with his behavioral plan on the unit.  He denied any suicidal ideation, homicidality or hallucinations.  He was future oriented.  He had been sleeping well and eating his meals.  He was tolerating his medications and the regimen was stable.  Although the patients chronically volatile relationship with his parents continued throughout the admission, these pervasive cyclical maladaptive behaviors were driven by the parent-child dynamic, not the result of an acute psychiatric syndrome. Thus, the acute services were not reasonably expected to significantly improve the patients condition or prevent a more serious illness. The services had become primarily custodial in nature while discharge planning continued. Accordingly, a less restrictive setting would have represented a safe and appropriate disposition consistent with current medical practice. Based on the documentation submitted for review and the relevant peer reviewed literature, it was not medically necessary for the patient to have been treated at an inpatient psychiatric level of care from the time frame specified.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX Anti-Reflux procedure for the treatment of his medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the data for the LINX procedure is from observational data and not from high-quality randomized controlled trials.  There is a lack of controlled data comparing the LINX procedure to a standard reflux operation, Nissen fundoplication.  All told, the LINX Anti-Reflux procedure is not likely to be more efficacious than other treatment options.  Final Result: Three reviewers determined that the requested 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for Norditropin Flexpro.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Idiopathic short stature (ISS). This is a boy with short stature. He also had a normal biochemical evaluation and was negative short stature homeobox (SHOX) gene. He has a family history of delayed puberty. There is insufficient evidence of whether this patient has ISS since no GH stimulation test was done. This patient has a growth velocity of 4.9cm/year (based on June 2017 and April 2018), which is a normal growth velocity and makes the diagnosis of growth hormone deficiency or ISS requiring growth hormone unlikely. No growth hormone (GH) stimulation test was done. The current height of the patient is not -2.25 SD below the mean. The estimated predicted adult height is not below 53 and is not 4 inches or more below the mid-parental height. The subjective and objective findings suggest the diagnosis of idiopathic delay of growth, and puberty, which does not require treatment with growth hormone.Final Result: The reviewer determined that the requested medication 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 pediatrics, with subspecialty 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: Upheld

A 56-year-old female has requested Oxycontin 60mg for treatment of lumbago status post back injury with fracture.  Findings:  The physician reviewer found that based on the records provided for review, authorization and coverage for Oxycontin 60mg, three times per day is not medically necessary for treatment of this patients medical condition. Such narcotics and at the doses prescribed are presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and if controlled release narcotics are indicated, treatment should be closely monitored by a certified pain management physician (Fishman). Baron and colleagues reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  As high dose opiates may also cause adverse outcomes, the patients request for Oxycontin 60mg three times per day is not clinically indicated. It would be in the patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. Any opioids as requested by the enrollee for her chronic pain would be in my opinion, contradictory to providing safe and effective health care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient presents with a medical diagnosis of autism, a complex neurodevelopmental disorder. Impaired verbal and nonverbal communication and impaired social communication are commonly observed in individuals with autism. Speech and language therapy is well-recognized as one of the multiple therapeutic modalities utilized in the treatment of autism spectrum disorders. This is noted in the practice guidelines of the American Academy of Child and Adolescent Psychiatry and the medical literature.  In this case, speech and language therapy has been prescribed by a developmental pediatrician.  A formal evaluative report by a licensed speech and language therapist indicates a history of unusual speech in terms of pitch, volume, and rhythm. The patient also displayed unusual repetition of final sounds and syllables. The recommendation was continued therapy for speech, language, pragmatic and social communication skills for at least one more year.  The record indicates the patient has a medical disorder (autism) with documented deficits in communication. As such, speech therapy services were and are medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for the cystatin C blood test. The enrollee has a history of cerebrovascular accidents. The enrollees medical history includes hypertension, diabetes, hypothyroidism, moderate non-proliferative diabetic retinopathy and nuclear cataracts in both eyes. The enrollees physician referred the enrollee to a nephrologist, due to severe hypertension with multiple strokes. Lab results showed the enrollees cystatin C level was elevated. Serum creatinine level is consistent with the diagnosis of kidney disease. Scientific evidence in peer-reviewed literature does not show a result of improvement in health outcome in using the serum cystatin C level as likely to be more beneficial than the standard testing of serum creatinine level. When comparing cystatin C-based glomerular filtration rate estimates to creatinine-based GFR glomerular filtration rate, studies showed precision may be worse with cystatin C-based estimates. Some guidelines recommend using serum creatinine as the initial test. Therefore, at the current time serum cystatin C measurement does not have any value over the standard measurement of serum creatinine in the diagnosis of kidney disease. The cystatin C blood test is used as a confirmatory test when the diagnosis is uncertain. In addition, it is reasonable to use cystatin C blood testing in patients with clear reductions in muscle mass that are otherwise reasonably healthy. This enrollees diagnosis of kidney disease is certain and he does not have a significant reduction in muscle mass. The cystatin C blood test has not been proven to change any clinical outcomes in any patient compared to standard testing of kidney function. Final Result: Three of the three reviewers determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in nephrology 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: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Urgent Care
Decision: Upheld

A 50-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he 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 patient presented with six days of ear pain that had peaked four days earlier and was improving. He continued to have a headache, but he had a history of migraine headache. The records noted that the patient was in no distress. Furthermore, the patient did not require any testing or pain medications while he was in the emergency department. While this patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to seek emergency medical attention.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested residential treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience and mental wellness.  In this patients case, substance use was problematic but the patient had not pursued specialty care at a less restrictive setting during this episode, such as intensive outpatient or partial hospitalization with augmentative 12-step programming in the community.  Upon presentation, the patient was motivated for treatment services.  She was not experiencing a withdrawal syndrome, and she was sleeping well.  The patient had mood symptoms, but these symptoms appeared to be related to her drug use, family stress and bereavement.  She was not diagnosed with a distinct affective disorder, and she did not have an acute psychiatric syndrome.  Per the medical records, the patient did not pose an imminent risk danger to self or others due to her depression.  While admitted, the patient was started on naltrexone, an opioid receptor antagonist used to treat opioid use disorders.  This medication helps particularly with craving and does not require a 24-hour supervised setting for initiation and titration.  Additionally, she was not having difficulty maintaining her self-care or activities of daily living.  The patient had a stable home environment.  Finally, the documentation provided did not offer a rationale supporting the clinical need for residential placement as opposed to treatment at a lower level of care.  All told, residential treatment provided from the time period specified was not medically indicated for the treatment of this patient.