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

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of approximately 25% with normal receptive language abilities, per the Rossetti Infant-Toddler Scale and Developmental Assessment of Young Children. There is no noted delay in play skills or pragmatics.  Speech therapy is indicated with any delay greater than 25%. An extensive review of the literature, including a meta-analysis by Law et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman et al. note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. However, approximately 50% of children delayed at 2 years catch up to their peers by 3 years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Receptive delays that are greater than expressive delays are more concerning. Children involved in early intervention services with parental interaction and teaching show stronger language skills than children who did not receive early intervention. This patient is currently involved in early intervention services and speech therapy is not medically necessary at this time. A repeat speech and language evaluation is recommended at 30 months of age to monitor progress.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for antibiotic protocol therapy services. The European League against Rheumatism (EULAR) recommendations for the treatment of systemic sclerosis are made according to the level of organ involvement and specific clinical manifestations. As per the EULAR statement, Raynauds phenomenon is treated with calcium channel blockers such as nifedipine and phosphodiesterase-5 inhibitors including sildenafil. For severe Raynauds that has persisted despite oral therapy, intravenous iloprost should be considered. Digital ulcers have been demonstrated to respond to iloprost, phosphodiesterase inhibitors, and bosentan. The recommendations also indicate that methotrexate has been shown to be effective for the treatment of skin changes in early diffuse systemic sclerosis while proton pump inhibitors can be effective for acid reflux. Current studies do not support antibiotic protocol therapy to treat the skin thickening and acid reflux this patient is experiencing as clinical manifestations of her systemic sclerosis, or to address her Raynauds with digital ulcers. The patients records do not include evidence of small intestine bacterial overgrowth, which would warrant treatment with antibiotics. For these reasons, antibiotic protocol therapy services and future antibiotic protocol therapy services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 rheumatology 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 patient has requested reimbursement for transabdominal cerclage procedure. According to current American College of Obstetricians and Gynecologists (ACOG), The inability of the uterine cervix to retain a pregnancy in the second trimester is referred to as cervical insufficiency. Per the ACOG recommendations, this patients clinical history and presentation supported treatment with a transvaginal cervical cerclage. However, the patient elected to undergo transabdominal cervical cerclage, which is a procedure reserved for patients who have failed transvaginal cerclages or have anatomic challenges that makes a transvaginal cerclage impossible. In addition, transabdominal cervical cerclage carries greater risks than transvaginal cerclage. Based on the available medical records, this patient does not meet the clinical criteria for a history-indicated transabdominal cerclage. For these reasons, the transabdominal cerclage procedure was not medically necessary for treatment of this patient.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential mental health and substance use treatment program for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient had mild withdrawal symptoms and had been started on the Librium taper in her emergency room visit, which did not require residential level of care to continue. She showed no evidence of being a danger to self or others. She was cognitively intact and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She was medically and psychiatrically stable.  She had prior treatments with an extended period of sobriety (nine months). She had experience in the 12 step process with a sponsor, even though she had continued drinking.  She was motivated. Relapse risk is inherent in the substance abusing populations and cannot be the sole reason for residential treatment. This patient did not require 24 hour per day, 7 days per week supervision.  She could have received treatment at a lower level of care. 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 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 parent of a two-year-old male enrollee has requested for one hour of physical therapy per week and one hour of occupational therapy per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that physical therapy evaluations demonstrate that the patient has significant functional deficits that require physical therapy at this time. The records indicate the patient has mild to moderate delays in stationary development, but he also has achieved major milestones at age-appropriate levels. For these reasons, there is inadequate justification for the medical necessity of physical therapy. the goals outlined by the non-plan occupational therapist include imitating a vertical line, horizontal line, and circle after two demonstrations; stringing three small beads consecutively; removing the lid from a bottle and placing small objects into a bottle using superior pinch grasp; imitating three block bridge using cubes; and snipping with scissors. These goals are not related to functional deficits such as dressing skills, hygiene, feeding skills or other activities of daily living.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male has requested a gait analysis study for evaluation of his intoeing.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  Intoeing describes a pattern where the feet point inward towards each other rather than parallel to each other.  In severe cases, this negatively impacts a childs ability to ambulate normally.  Long-term sequelae of uncorrected intoeing include patella-femoral pathology, abnormal subtalar joint pronation, hip joint arthrosis, and patella instability.  Multiple different pathologies, structural or postural, may result in this gait pattern, including metatarsus adductus, excessive femoral antetorsion, medial tibial torsion, cerebral palsy, and weak or dominated lateral hip rotators.  As noted by Uden and Kumar, an effective management plan requires the accurate diagnosis of one of these underlying pathologies.  This patient has significant intoeing that is negatively impacting his ability to participate in ambulatory activities.  A comprehensive clinical assessment has not yielded the specific etiology responsible for his intoeing.  Thus, the requested gait analysis study is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication Otezla. Otezla has been approved by the U.S. Food and Drug Administration (FDA) for treatment of patients with disseminated plaque psoriasis. This patient has disseminated plaque psoriasis that requires systemic treatment. Anti-tumor necrosis factor drugs can increase the risk for malignancy. Prior treatment with Otezla provided this patient with substantial relief of symptoms. The use of Otezla, which does not increase the patients risk of malignancy or infection, is warranted under these circumstances. Thus, Otezla is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus genotype 1a.   Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to nonliver-related comorbid conditions. Patients who have failed treatment with peginterferon-based regimens are recommended to be re-treated with daily Harvoni for 12 weeks. Based on published evidence of safety and efficacy in the medical literature, and clinical guidelines, the requested treatment consisting of Harvoni for 12 weeks should be considered medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an electrical osteogenesis stimulator for treatment of the enrollees medical condition status post multilevel fusion surgery of the neck.  Findings:  The physician reviewer found that the requested electrical osteogenesis stimulator is medically necessary for treatment of the patients medical condition. Successful fusion surgery of the spine necessitates the formation of bridging bone between segments where surgery occurred. Failure of this bone formation can potentially result in pain and spinal instability. Bone growth (osteogenesis) stimulators are externally worn devices that use electromagnetic fields to enhance bone formation. The use of bone growth stimulators after surgery in the lumbar spine is well accepted in the peer-reviewed literature. A large prospective study by colleagues demonstrated that electromagnetic field stimulation for cervical fusion significantly increased the rate of healing. In this case, the providers recommendation for the requested device are in accordance with the North American Spine Society (NASS) policy recommendations. NASS supports the use of electrical stimulation for spinal fusion healing in all regions of the spine including cervical and lumbar regions. Additionally, NASS policy is consistent with community standard of care. Given the support in the peer-reviewed literature, the requested device has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested device 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 neurological 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that 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 the dense breast. Helvie noted that breast tomosynthesis technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. Rafferty and colleagues concluded that, addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. However, in this particular patient, there were no indications for the additional imaging with digital breast tomosynthesis. Specifically, the patient did not have dense breasts, a mass, or a palpable lump, and she did not have calcifications. Given the extra exposure to radiation, tomosynthesis is not routinely performed in all patients. Thus, the breast tomosynthesis was not likely to have been more beneficial for evaluation of this patients medical condition than any available modality including standard mammogram.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology 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 patient has requested authorization and coverage for arthroscopic left shoulder surgery to include arthroscopic rotator cuff repair and arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures. The available records indicate that this patient is being treated for left partial-thickness tear, left rotator cuff tendinopathy, and left subacromial bursitis. The patient reports having difficulty reaching overhead and to reach behind his back. The patients left shoulder examination revealed subtle scapulohumeral asynchrony as he elevated to the mid-range. The provider has recommended left shoulder arthroscopy with rotator cuff repair surgery. However, there is a lack of documentation of attempts at recent, reasonable, and comprehensive less invasive conservative care measures. In addition, there is a paucity of large-scale, long-term studies in the peer-reviewed medical literature demonstrating the safety and efficacy of arthroscopic shoulder surgery for treatment of this patient. McElvany and colleagues noted that, future clinical studies on the outcome of rotator cuff repair must report important data relating to each patients condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function. Given these findings, the requested arthroscopic left shoulder surgery to include arthroscopic rotator cuff repair and arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures is not medically necessary for 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program level of care for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was processing her trauma while the updated treatment plan noted that she was successfully articulating and implementing coping skills.  The patient was motivated for treatment and had a safe residence and supportive family.  During the episode of illness, she had not previously engaged in evidence-based therapies for posttraumatic stress disorder and bipolarity, such as cognitive processing therapy or prolonged exposure and cognitive behavioral therapy, family therapy or interpersonal therapy, respectively.  This last item is particularly significant in this case for two reasons: first, modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that treatment provided in a less restrictive treatment setting, such as an intensive outpatient program with community support groups, would have been insufficient at the time.  Thus, partial hospitalization program level of care was not and is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 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 patient is a 3-year, 10-month-old female who was born the product of a triplet gestation and has a history of developmental delays.  She did not walk until two to two and one half years of age. The patient has had difficulty with both fine and gross motor skills.  In the July 2005 occupational therapy (OT) evaluation of gross motor skills it was noted that she was unable to jump in place or jump forward, could not descend stairs without crawling, and could not maintain balance while standing on either her left or right leg alone.  In the area of fine motor skills, the therapist noted that the patient used a palmar grasp for writing and was not consistently able to use a pincer grasp for picking up objects.   She was also unable to fasten a one-inch button. It was recommended that the patient continue with occupational therapy, and her parent has requested authorization.  The Health Plan had denied this request based upon their determination that continued OT is not medically necessary.I have reviewed the occupational therapy evaluation from July 2005, the reports from the infant program, and the October 2004 progress report from the behavior consultant. All of the assessments document significant delays. In the report provided by the behavior consultant, the patient is described as having a limited attention span, distractibility, echolalia, sing-songy language, splinter skills, no eye contact, no interaction with peers, perseverative play and rigidity in her routines.  Although there is no formal diagnosis of autism, these symptoms are associated with the autism spectrum as are the fine and gross motor skill delays. It is not reasonable to conclude that the patients developmental delays are of the type commonly seen in multiple births or that they will self correct within a reasonable number of years. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 79-year-old female enrollee has requested vaginal vault suspension and anterior repair with suburethral sling and mesh placement for treatment of her uterine prolapse and cystocele.  Findings:  The physician reviewer found that in reviewing American College of Obstetricians and Gynecologists (ACOG) practice guidelines, pessary use may be considered prior to surgical intervention in patients with symptomatic pelvic organ prolapse. There should be a documented assessment by the surgeon regarding the option of pessary use, including the rationale for using or not using, such as patient discomfort, technical contraindications such as not being able to fit one, or patient refusal. However, pessaries have not been objectively demonstrated to improve incontinence symptoms. In addition, ACOG suggests that colpoclesis should be considered in patients at high risk for complications and who are not sexually active. All told, the requested surgical intervention is supported as medically necessary for treatment of this patients medical condition.