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

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, the requested speech therapy is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for continued skilled nursing facility services.Spinal decompression surgery is generally known to be more effective than conservative care for the treatment of lumbar spinal stenosis that causes pain and neurological dysfunction. Postoperatively, multidisciplinary rehabilitation plays a significant role in the restoration of function and community reintegration.In this case, the submitted documentation reflects that the patient has had significant overall dysfunction since her spinal decompression surgery. Records reflect that the patient made only modest to minimal progress over many weeks of multidisciplinary rehabilitation. The patient continued to require minimum assistance for her transfers and she plateaued with respect to ambulation at the minimum assistance level for household distances. The patient was otherwise independent with wheelchair mobility. Records indicate that she continued to require moderate to maximal assistance for lower body self-care. There was no clear plan in the submitted documentation concerning how the patient would be realistically and safely reintegrated into the community. There was also no indication in the patients medical records that she is reasonably expected to progress to a fully independent level, given the magnitude of her functional deficits and her lack of significant progress to date. There were otherwise no other skilled nursing or medical needs requiring ongoing inpatient level care. Under these circumstances, continued skilled nursing facility services were not, and are not, medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary for treatment of the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 patients parent has requested reimbursement for mental health residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to recent repeated episodes of self-harm, suicidal ideation with a plan prior to admission, and disordered eating of purging and restricting to 200 calories per day. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict as demonstrated by a tense home environment and family conflict. The patient reported struggles with hygiene due to low mood, and disordered eating.With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of occasional cannabis use.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to struggles with expectations from her parents. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents active participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment as multiple medication trials had not prevented her recent decline in mood and functioning. With regard to treatment acceptance and engagement, the records support a score of 2, due to patients active participation in treatment. Thus, the patient had a total score of 20. In this case, the recommended level of care was medically monitored residence-based services due to the risk of harm and functional status scores of 4. This is consistent with the level of care that the patient received at the RTC. Therefore, RTC services were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 11-year-old female with type I diabetes who is on an insulin pump (Medtronic Minimed). She has been denied coverage for BD Logic blood glucose test strips for use in the attached Medtronic Minimed blood glucose monitor. The BD Logic strips are required for this glucose monitor, which records the blood glucose level electronically in the pump. The Health Plan indicates other test strips are available for monitoring of the patients medical condition.In terms of medical necessity, the patient must have the ability to measure blood glucose levels five to eight times daily when on an insulin pump. The reagents used to do this (monitor and strips) are required as a medical necessity. However, there are large numbers of medical glucose sensing systems that could accomplish this. Though BD Logic test strips may be more convenient, there is no evidence demonstrating the requested supplies are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for the enrollee's breast cancer screening evaluation. Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the presence of asymmetry is an appropriate indication for breast tomosynthesis, as tomosynthesis can better separate out the overlapping structures, thus enabling the possibility of demonstrating an otherwise occult tumor.  Similarly, the heterogeneously dense nature of her breasts is another indication for breast tomosynthesis.  Based on the current medical evidence, breast tomosynthesis is likely to be more effective than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue 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: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

A 53-year-old male has requested coverage for a past  consultation/evaluation and transcranial magnetic stimulation (TMS) treatments for his depression.  Findings:  Two physician reviewers found that the patient has a history of major depression and anxiety. He has been having symptoms of depression and had been tried on psychotropic medications including Cymbalta, Sertraline, Zyprexa, Abilify, Seroquel, Celexa, Effexor, Paxil and Wellbutrin. The patient was recommended for transcranial magnetic stimulation (TMS) therapy following consultation with his provider. This patient had a BDI, HAM, and MADRS and his scores were 44, 32 and 40 before TMS therapy and were reduced to 34, 13 and 26 respectively. This patient presents with a diagnosis of major depression and anxiety that has been refractory to numerous medication trials of antidepressant medications. Given his failure to respond to more than one pharmacologic agent, he was recommended for TMS by his treating psychiatrist. In the peer reviewed medical literature, TMS is described as effective and safe for patients who have failed to respond to previous therapies with minimal, if any, negative side effects. In addition, TMS has been approved since 2008 by the Food and Drug Administration. Consistent with these data, the TMS therapy was clinically indicated since he had not responded to conventional medications or procedures for the treatment of his sustained depression.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested Cialis for the treatment of his prostate cancer, status-post prostatectomy. Findings:  The physician reviewer found that Cialis is a 5-phosphodiesterase inhibitor which helps with the recovery of erectile dysfunction associated with radical prostatectomy. The recovery of erectile dysfunction following surgery is variable and depends on a number of factors including preoperative function, and the ability to avoid damage to the nerves at the time of surgery. It is clearly documented that the use of medication such as Cialis improves sexual performance and satisfaction over the use of placebo alone and there are several studies which demonstrate this fact. However, the number of pills required, the length of time the medication is needed, and whether the medication should be used nightly or simply on demand is unknown. Studies have not shown any particular program to be superior, including daily use versus on-demand use (see Montorsi and colleagues, 2008). Generally, medications such as Cialis are prescribed by urologists to be used several times per week in the hope that increased blood flow to the corpeal bodies of the penis will speed spontaneous recovery of erections. The number of pills (12 per month) requested for this patient is without scientific basis. The length of time the medication should be taken for maximum effect post-prostatectomy is similarly not established in the medical literature. Thus, at this time, without more studies to show the advantage of the proposed medication schedule and quantity, the medical necessity of the request has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Orthovisc bilateral knee injections and ongoing Orthovisc injections (series of four) for treatment of his medical condition.    Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  In the setting of osteoarthritis of the knee, viscosupplementation does not lead to clinically meaningful improvement.  Published clinical trials comparing injections of viscosupplementation with placebo have yielded inconsistent results.  Higher quality and larger trials have generally found lower levels of clinical improvement in patients and function than small and poor quality trials.  In sum, the services at issue were not and are not likely to have been more effective than other treatment options.  Final Result: Two reviewers determined that the services at issue were not and 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 reviewers are board certified in orthopedic surgery 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 60-year-old male enrollee has requested for residential treatment services for treatment of his alcohol dependence. Findings:  The physician reviewer found that the patient met the established criteria for admission to a residential treatment program. At that point, he required structured 24-hour care for stabilization. The patient needed to establish his long-term rehabilitation program and to make a commitment to sobriety. He had previously failed to follow through in the outpatient setting. This could have reasonably been accomplished in a 14-day residential program.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested for transcranial magnetic stimulation therapy for treatment of his depression. Findings:  Two physician reviewers found that the patient does not appear to have any comorbid substance abuse or personality disorders.  This is significant, as most of the literature supporting transcranial magnetic stimulation considers comorbid disorders to be exclusionary. The evidence base for transcranial magnetic stimulation has grown over the past several years, and this treatment has gained FDA authorization for the treatment of depression.  There is evidence that it can be effective in patients who have been medication-resistant, as noted by Avery and colleagues in 2006. There was significant evidence for the use of transcranial magnetic stimulation therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested an ultrasound or MRI for an evaluation of her breast microcalcifications. Findings:  The physician reviewer found that it is well-established in the medical literature that mammography is the appropriate imaging study for the evaluation of breast calcifications. This has been the standard of care for several decades. Further, it is well-documented in the peer-reviewed literature that ultrasound and MRI are not adequate for the evaluation of breast microcalcifications.  As noted by the National Cancer Institute, ultrasound is not used for routine breast cancer screening because it does not consistently detect certain early signs of cancer such as microcalcifications, and MRI also cannot detect microcalcifications. Breast calcifications fall into three categories, benign, indeterminate and malignant.  Those calcifications that are indeterminate or malignant in appearance are referred for biopsy. Benign calcifications are followed by mammography. If the calcifications are new, short-term follow-up mammogram is sometimes indicated. In regards to this patient, she was referred for a short-term follow-up mammogram to evaluate new benign appearing calcifications, which is consistent with the standard of care in this setting. Ultrasound and breast MRI are not medically necessary to evaluate breast calcifications as they have not been shown to be effective for this indication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for robot-assisted laparoscopic hysterectomy with the da Vinci Robot.Findings:  The physician reviewer found that this patient has had chronic pelvic pain and painful periods since her early teens. She has undergone treatment with a full complement of medical options for painful periods and pelvic pain without adequate relief. Other etiologies have been ruled out. She has consulted with two providers who concur that she is a candidate for hysterectomy, ideally by robotic laparoscopic approach due to her obesity. The providers have appropriately planned for surgery on the adnexae based on findings, plus an elective appendectomy due to her right lower quadrant pain, plus surgical management of endometriosis, if needed. There is an indication for proceeding with a hysterectomy is because at least some, perhaps all of her pain, is related to her uterus. In addition, the providers plan is to address any endometriosis at the time of surgery if found. All told, the requested robot-assisted laparoscopic hysterectomy with the da Vinci Robot is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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: Upheld

A 29-year-old male enrollee has requested a custom, functional knee anterior cruciate ligament (ACL) brace for treatment of his medical condition. Findings:  The physician reviewer found that this patient is status-post anterior cruciate ligament (ACL) reconstruction and has full knee range of motion and good stability on his post-operative knee. Bracing after an ACL injury has been extensively researched and the latest literature does not support the use of post-operative bracing after ACL reconstructive surgery. Although the patients work requires him to negotiate hazards and obstacles on his feet, the literature on prophylactic bracing to prevent the rate and/or severity of re-injury of an ACL tear (post-surgery) is inconclusive. Since this patient was doing satisfactorily with his rehabilitation program, and the current literature does not specifically support the contention that prophylactic bracing reduces the rate and/or severity of ACL re-injury, the medical necessity of a custom, functional brace is not supported.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a panniculectomy. The enrollee underwent gastric bypass surgery four years ago; with a 90-pound weight loss. The enrollee has noticed odor and irritation at her navel for the past two years. She has treated the area with cleaning and ointments, but the odor and redness is still present. Her physician recommended plastic surgery. Studies show this type of surgery is not cosmetic, but a needed surgery to fix the problems of odor and redness.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 plastic 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for one hour a week of the Schroth method of therapy. Findings:  The physician reviewer found that Kalichman and colleagues state that bracing has been found to be the most effective conservative treatment for adolescent idiopathic scoliosis (AIS). However, there is limited evidence that specific physical exercise is also an effective intervention for AIS. Additionally, well-designed and good quality studies are required to assess the effectiveness of different conservative methods in treating AIS. Further, a review by Romano and colleagues found that the effectiveness of manual therapy for the treatment of idiopathic scoliosis remains unclear. In a review of the medical literature, Lotan and Kalichman could not come to a clear conclusion about the effectiveness of manual therapy in the treatment of AIS. Ng and colleagues state that the difference among the many physiotherapeutic scoliosis-specific exercises (PSSEs) and braces has not been studied. As such, no specific PSSE can be recommended. Thus, one hour a week of the Schroth method of therapy is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings: Two out of three physician reviewers found that one hour a week of the Schroth method of therapy was not likely to be more beneficial for you than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in orthopedic surgery and is 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.