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

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested reimbursement for the residential treatment services provided for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). On admission, the patient was at significant risk of harm (score 3) with a recent suicide attempt by overdosing on Prozac. Per documentation, the patient is impulsive and has an all or nothing mind frame and is either feeling better or suicidal and depressed. The patient demonstrated moderate functional impairment (score 3) since although she is intelligent and doing well in school, she has some moderate impairment when she will feel overwhelmed due to normal psychosocial stressors. The patient presented with significant co-morbidity (score 3) with major depressive disorder, generalized anxiety disorder, social (pragmatic) communication disorder, and premenstrual dysphoric disorder. However, the patient did not have any medical problems which required 24-hour monitoring. The patient had a mildly stressful recovery environment (score 2), which was supportive (score 2), and the patient had demonstrated equivocal resiliency and response to treatment (score 3). The patient has been constructive in treatment (score 2) and is described as cooperative and friendly. This gives the patient a composite score of 18, which is consistent with intensive outpatient program (IOP). Thus, the patient could have been treated in a less restrictive environment. This is consistent with the recommendations of the provider to treat the patient with more structure and biweekly therapy, yet allowing the patient to be treated in a less restrictive environment. The patient continued to need treatment for her depression and anxiety, but this could have been done in a less restrictive environment. Therefore, the residential treatment services provided were not medically necessary and that the patient could have been treated in a less restrictive environment. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for SoClean, automated continuous positive airway pressure (CPAP) equipment sanitizer. The enrollee has upper airway resistance syndrome with fragmented nocturnal sleep and excessive daytime sleepiness. She has co-morbidities of hypertension and borderline diabetes.  Pulmonology progress notes indicate an automated continuous positive airway pressure (CPAP) machine was prescribed with a re-evaluation in six to eight weeks.  The records indicate good objective compliance and resolution of symptoms. However, the enrollee reported she had not been able to use her device for several months due to recurrent upper airway infections and dizziness, despite cleaning of the equipment. Studies demonstrate improvements to sleep-related breathing disorders when positive airway pressure (PAP) therapy is utilized. This enrollee used a CPAP unit due to such a disorder. Studies demonstrate CPAP use in obstructive sleep apnea (OSA) patients does not increase upper and lower respiratory tract infections. Despite positive cultures found in CPAP masks in the studies, the patients experienced no higher levels of infection. Although poor equipment cleaning was exhibited in the study population, the association between CPAP use and infection remained negligible. Additionally, CPAP has been in use for 37 years. Cleaning of the equipment with liquid dish soap and hot water has been the standard of care and used for decades. No scientific data demonstrates the use of SoClean, an automated CPAP equipment sanitizer, is better than the usual measures recommended to clean the CPAP machine. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep 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: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested laser/microwave vein surgery (including CPT codes 36470, 36471, 36475, 36478, and 36479)for treatment of his varicose veins.   Findings:  Two physician reviewers found that this case involves an atypical pattern of the venous disease. The patient previously underwent treatment of the refluxing saphenous vein and now has symptoms that are related to a refluxing perforator. The evidence for the efficacy of the treatment of perforators is somewhat limited (ODonell), but it is generally accepted that some patients will benefit from this therapy, particularly after the saphenous disease has been treated. There are a number of papers in the literature supporting the requested treatment approach using both laser and radiofrequency techniques as an energy source (Hingorani, et al., Black et al., and Peden and Lumsden). As this patient has had treatment of the refluxing veins the other branches typically would be treated as well (i.e., he has had treatment of the refluxing segment of the greater saphenous vein). All told, the patient is an appropriate candidate for the services at issue and there is adequate evidence to support the use of these interventions in this particular case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested speech therapy for the treatment of the enrollees articulation disorder and dysarthria. Findings:  The physician reviewer found that developmental delays including speech are common following prematurity, especially for those born at 25 weeks gestational age. The etiology of the language delay in prematurity is unclear. Individualized speech therapy is not generally considered clinically or medically indicated in this group of patients. The submitted documentation demonstrates that this patients deficits are educational in nature and do not warrant individualized private speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia and continued pelvic pain.  Findings:  The physician reviewer found that this patient has a chronic pain syndrome related to lumbar spine surgery. Several providers noted multiple trigger points and include a diagnosis of fibromyalgia. While the records do not outline a formal description that confirms a diagnosis of fibromyalgia as defined by the American College of Rheumatology, the patient reportedly has multiple trigger points. The patient has had good pain control with Lyrica. Further, the records indicate the patient has failed tricyclic antidepressants and an anticonvulsant. Given a diagnosis of fibromyalgia, the fact that Lyrica is indicated for fibromyalgia and the patient has experienced a proven response without significant side effects, Lyrica is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested a TLSO (thoracolumbosacral orthosis) brace and device (L3580-O shoe add instep, Velcro closure) for the treatment of the enrollees kyphosis. Findings:  The physician reviewer found that a TLSO brace meets the Health Plans criteria of DME (durable medical equipment) and medical necessity as DME. The brace will support the patients deformed spine and it will facilitate healing. Even though the patients kyphosis is correctable by voluntary postural effort, due to his developmental disabilities, he is unable to follow through with medical instruction to self-correct. The TLSO brace is medically necessary to prevent and correct his kyphosis, as the patient is not capable of self correction or exercises on a consistent basis due to his developmental disabilities. However, the instep Velcro closure for his shoes (L3580-O shoe add instep, Velcro closure), is not medically necessary, as there is no foot deformity or weakness documented in the submitted medical records.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a nerve conduction study. This patient has numbness in the left fourth and fifth digits. The differential diagnosis included ulnar neuropathy at the elbow, cervical radiculopathy, and lower trunk plexopathy. The documentation reveals that the provider suspected radiculopathy and performed a nerve conduction study. However, without needle electromyography (EMG), radiculopathy cannot be confirmed or excluded. There was no discussion of possible ulnar neuropathy or other compression neuropathy in the progress notes. Furthermore, without a thorough needle EMG, the provider may miss a diagnosis of a plexopathy. Additionally, the patient has shoulder pain and pain radiating into her arms. She was diagnosed with polymyalgia rheumatica but not with EMG. Without the needle EMG, the NCS alone is an incomplete study for this patients symptoms. There are no extenuating factors in the documentation such as upper extremity lymphedema, significant thrombocytopenia, or upper extremity infection where there could be a contraindication to needle EMG. Therefore, the nerve conduction study was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. One Reviewer is board certified in physical medicine and rehabilitation and is actively practicing.  One Reviewer is board certified in physical medicine and rehabilitation and is 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 53-year-old male enrollee has requested a Roll-A-Bout walker to help his mobility. Findings:  The physician reviewer found that the patient has a prior history of shoulder surgeries and right-sided carpel tunnel surgeries. The record includes documentation from his orthopedic surgeon stating he should not bear weight with his shoulders and therefore should not utilize crutches or a standard walker. Given this set of circumstances, the Roll-A-Bout walker was the appropriate equipment for the enrollees mobility following surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The submitted documentation does not support the medical necessity of the requested sclerotherapy for treatment of this patients lower extremity varicose veins. There is a lack of documentation ruling out other etiologies that may be the source of the patients leg pain. The patient is noted to have abnormal pedal pulses in the setting of hypertension and hyperlipidemia. The patient presented without complaints status post left greater saphenous vein ablation. In the absence of documentation that the patient has undergone thorough evaluation to rule-out other causes of her symptoms, the requested sclerotherapy is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 surgery with sub-specialty certification in vascular 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) services. In the medical literature, researchers reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors noted that the age at which ABA therapy was started and duration of treatment was correlated with outcome. Other researchers reached similar conclusions. The records indicate that this patient has been receiving 30 hours per week of ABA therapy and has made significant progress in language skills, social skills and independent living skills. There has been an overall decrease in maladaptive behaviors since ABA therapy was introduced. Thus, continued ABA services are indicated. However, the records do not support that the requested 40 hours per week of ABA services are medically necessary for treatment of this patients medical condition. 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 pediatrics and neurology with special qualification in child neurology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for air ambulance service provided on 12/27/17. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees epilepsy.At issue in this case is whether the requested air ambulance service was medically necessary for treatment of the enrollees medical condition.In most cases, air ambulance transport is reserved for use in emergent situations in which ground transport is not feasible or readily available. Such situations from the neurology perspective include (but are not limited to), intracranial hemorrhages, strokes requiring endovascular therapy or other conditions requiring acute surgical intervention. In this case, the clinical documentation provided for review suggests that the patient presented to the hospital with a prolonged seizure and altered mental status for which he was successfully intubated and sedated at the initial hospital. He was said to have been loaded with medication. There was no mention of continued/further seizures. The patients computed tomography scan of the head was also negative for any acute process. In such a clinical setting the standard of care would have been to stabilize the patient and to treat their seizure (or possible status epilepticus--if present). If it was felt that a higher level of care was necessary for the ongoing management of the patient's condition, then the current standards of care indicate that the patient should be transferred to the closest available medical center. In this case, the patient appears to have had his condition stabilized at the originating facility. In this setting the patient would likely have been able to have been transported via ground ambulance to a local facility (local to the originating site) that provides a higher level of care such as those identified by the Health Plan. Rather, in this case, the patient was transported approximately 600 miles back to the United States for a non-emergent medical condition. This trip would have otherwise been considered to have exceeded the patients clinical needs. Nor was the inter-facility transport provided/performed to the closest medical facility able to provide adequate medical services for the patients condition. The air ambulance services provided in this case would not be considered to have furnished services consistent with the generally accepted standards of practice or care. Therefore, the service would not have been medically necessary.Final Result: The reviewer determined that the requested service 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested  for speech therapy for treatment of his delayed speech. Findings:  The physician reviewer found that Nelson and colleagues reports that speech and language development is a useful indicator of a childs overall development and cognitive ability and is related to school success. Additionally, they note that language-delayed children have also shown more behavior problems and impaired psychosocial adjustment.  From this detailed account, it is clear that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers conclude that this meta-analysis shows overall 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 at least some children with a history of severe phonological impairment.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management System.  Findings:  Three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX Reflux Management System is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Medical guidelines for the management of reflux disease also state that more evidence is needed before LINX Reflux Management System can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. For these reasons, LINX Reflux Management System is not likely to be more efficacious than other treatment modalities.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an oral appliance for treatment of chronic headache. Findings:  The physician reviewer found that there is insufficient evidence in the medical literature to support the medical necessity for the device at issue in this clinical setting. This patient had presented with complaints of chronic headache, jaw pain and a compromised nasal airway. The patients orthodontist had assessed the patient for maxillary hypoplasia, maxillary asymmetry, mandibular discrepancy to cranial base, headache and jaw pain. The orthodontic provider recommended treatment beginning with palatal expansion. Palatal expansion is a treatment option, which is recognized to correct a patients dental malocclusion. However, the use of this device for the treatment for headache is uncertain and not well supported in the medical literature. Final Result: The reviewer determined that the device at issue was 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 oral and maxillofacial 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.