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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient psychiatric level of care. This patient began intensive outpatient program level of care approximately one month prior to the Health Plans denial. The progress notes indicate the patient is cooperative in treatment. She is not aggressive with others in the program. She has not expressed suicidal or homicidal ideation or psychosis. The records do not indicate that she has used substances during the disputed timeframe.In cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1 due to the patients lack of current self-harm ideation. With regards to functional status, the records support a score of 1. The patient has had deterioration in expected level of functioning in relationships with family, but overall appeared functional day to day. In terms of comorbidity, the records support a score of 1. The patient does not have any active serious medical problems or active substance use. With regards to level of stress of the recovery environment, the records support a score of 2. The patient has issues with family relationships family but has a stable housing situation. In terms of level of support of the recovery environment, the records support a score of 1. The patients father is actively involved in treatment and attended family sessions on a regular basis. With regards to level of support of the recovery environment, the records support a score of 1. As noted above, the patients father is actively involved in treatment. In terms of resiliency and treatment history, the records support a score of 2 to 3. Although there is a lack of documented recent treatment, the patients behaviors have improved during her intensive outpatient program sessions. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participates in therapy, but does not appear to be motivated for treatment. In terms of acceptance and engagement of the parent, the records support a score of 2. The patients father has worked actively and constructively with clinicians. Thus, the patient has a composite score of 12 to 13. This score correlates with outpatient services. Therefore, intensive outpatient psychiatric level of care was not and is not medically necessary 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested hip arthroscopy with acetabuloplasty and labral repair for treatment of her hip pain and bone spur.   The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Based on the documentation submitted for review, the patient has documented objective changes of the left hip supporting a diagnosis of a pincher type of acetabular impingement with joint space narrowing and a superior osteophyte. The rationale for the appropriateness of arthroscopic acetabuloplasty is to either postpone or obviate the need for total hip replacement. This is particularly important in an otherwise healthy patient. The accepted incidence of revision arthroplasty after total hip replacement is at least 5% in five years. It is known that total hip replacement will subject the patient to a particulate load of wear debris and patients variably respond to this phenomenon. For these reasons as well as the careful work-up and assessments documented, it is medically necessary for this patient to have the proposed operative procedures. This includes the arthroscopic debridement of the trochanteric bursa and the arthroscopic release of the iliotibial band. In this case, the application of arthroscopic techniques to extra-articular pathology is an appropriate application of these surgical techniques. In sum, hip arthroscopy with acetabuloplasty and labral repair is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) procedure code 72148. Findings:  The physician reviewer found that the utility of MRI for patients with low back pain and radiculopathy and surgical intervention candidates with persistent or progressive symptoms during or following six weeks of conservative management. The ACR guidelines support MRI only if severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition are present, or if the patient is a candidate for invasive treatment approaches. Immediate imaging is recommended for patients with major risk factors for cancer, spinal infection, cauda equina syndrome, or severe or progressive neurologic deficits. This patient is being treated for bilateral low back pain with radiculopathy. The patient had an inpatient admission in September 2021, during which time she underwent a lumbar puncture. Since that procedure, the patient complains of persistent low back pain with radiation to both lower extremities. The patients symptoms may be associated with post-lumbar puncture adverse effects. However, the records fail to document that adequate attempts at conservative care have been attempted prior to consideration for an imaging study. There are limited large-scale, long-term references showing the safety and efficacy of the requested MRI in this clinical setting. Therefore, the request for MRI lumbar spine (CPT 72148) is not medically reasonable or necessary.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for group speech therapy. Based on this patients language scores, he is likely to benefit from one hour per week of individual speech therapy plus the addition of group speech therapy. He is currently being treated with ABA therapy and a social skills group therapy. He also receives speech therapy for one hour per week and occupational therapy for one hour per week. Based on his scores on language skills, he has delays in pragmatic language, overall listening comprehension, and oral expression. He requires individual speech therapy to address the listening comprehension and oral expression. He also has very low pragmatic skills testing at 4%, so he requires pragmatic language interventions, which are usually provided through group speech therapy (Adams, et al). All told, the requested group speech therapy for one hour per week is medically necessary for this patients medical condition.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for this young patient with ASD and history of expressive and receptive language delays with socialization deficits. In the medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The authors reported that the only significant predictors were motor imitation and number of hours of speech and language therapy. Overall, the patients with significant speech and language intervention improved in their language development. Similarly, Goldstein reviewed communication intervention for autism in the peer-reviewed research articles published over the past 20 years and found that effective interventions exist to teach communication skills to children with autism. The author concluded that language skills make a significant difference in the ability of children to control their environment. Further, Volmar and Weisner stated that language deficits are one of the core aspects of autism for which speech therapy provides professional guidance with communication development. For these reasons, this patient will benefit from speech therapy as part of a dedicated intervention program as it is medically necessary and consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee requested authorization and coverage of a liver biopsy. The Health Plan denied the request indicating that the requested service is not medically necessary for treatment of the enrollees psoriasis.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: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee requested genioplasty (CPT code 21123) for treatment of the enrollees bilateral temporomandibular joint (TMJ), adolescent internal condylar resorption (AICR), mandibular hypoplasia, and maxillary hypoplasia.  Findings:  The physician reviewer found that the patient has been diagnosed with bilateral condylar resorption, which is a maxillofacial skeletal deformity. Per the notes provided, the patient also has documented OSA. The surgery including the genioplasty was appropriate for the patients condition. The procedure was likely to result in improved musculoskeletal and dento-osseous relationships. Moreover, the procedure should provide an improved airway, including improvement of signs and symptoms of sleep disordered breathing. For these reasons, the genioplasty was medically necessary for treatment of this patients medical conditions. Moreover, performance of the genioplasty will help correct the patients developmental abnormality and create a more normal appearance. Consistent with these findings, the genioplasty performed was reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee requested authorization and coverage for a palatopharyngoplasty for the treatment of an airway obstruction.  The health plan denied the enrollee's request indicating that the requested treatment is not medically necessary.  One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plan's denial on the basis that the requested palatopharyngoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 70-year-old male enrollee has requested continued skilled nursing services for the treatment of his condition. Findings:  The physician reviewer found that this patient did indeed have recurrent C. difficile colitis causing diarrhea and one episode of fecal incontinence. The patient does not appear to have had any further documented fecal incontinence nor did he receive any bowel training from skilled nursing. He was receiving oral medications and was not receiving any skilled wound care. The patient did have loose stools due to C. difficile colitis requiring new treatment with vancomycin, but he did not require skilled nursing care for parenteral medications or bowel training or skilled observation (no physician order for any of these). He required custodial care only.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested additional intravenous Rocephin for the treatment of her Lyme disease. Findings:  The physician reviewer found that this patient has no recorded history of a tick bite and has symptoms not especially suggestive of Lyme disease. The definitive serological tests for presence of Borrelia infection were negative. Intravenous Rocephin is not medically appropriate for this patient. Specifically, there is no need for intravenous Rocephin for a three month period. The maximum recommended therapy for proven joint or nervous system Lyme disease is 28 days of ceftriaxone, as noted in the guidelines presented by Wormser and colleagues. As the patient does not have clinical evidence of Lyme disease, there is no justification in this case for the proposed therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested partial hospitalization treatment for the treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient has had numerous treatment failures in the past. In this patients case, when her treatment programs were prematurely ended, she relapsed quickly. Her condition would have likely deteriorated if she would have been moved to a lower level of care.  She has a long history of bulimia and has had multiple relapses. Her treatments in the past have not resulted in long-term success.  Due to her comorbid substance abuse issues, the literature supports the fact that she is in a difficult-to-treat subset of patients. Partial hospitalization treatment provided during the dates of service at issue was clinically indicated for this patient. During the dates of services at issue, the patient met American Psychiatric Association criteria for partial hospitalization program level of care as she needed further intensive services due to her comorbid conditions and history of treatment failure with rapid relapse/decompensation in the past.
Appeal type: Urgent Care
Decision: Upheld

A 21-year-old female enrollee has requested an emergency room visit for the treatment of her cough and fever. Findings:  The physician reviewer found that the patient had symptoms for six days and had no flare or complication of the symptoms. The need for emergent care is not supported in the medical record, as symptoms were not severe and remained unchanged for several days. The non-participating facility is reported to have urged emergent care based on a report of dizziness while waiting for the father to receive treatment. This was not substantiated in the records. Without more information, the dizziness can not be an indication for emergency treatment. A short episode of dizziness after six days of flu is not an indication for emergency care.  The symptoms did not rise to a level that indicated emergent care for a prudent layperson.
Appeal type: Medical Necessity
Decision: Overturned

A forty-two year-old obese female with multiple comorbidities is requesting authorization for Lap-Band surgery.Reviewers Findings:  The reviewing physician found that the clinical information provided demonstrates that the patient is a suitable candidate for Lap-Band surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested  thighplasty (thigh lift) for treatment of her excess skin status post bariatric surgery and weight loss.  Findings:  The physician reviewer found that obesity can be considered a disease. In this patients case, correction of this disease has led to the abnormal structures of significant skin overlap. The patient has a probable functional deficit related to the skin overlap. The patient complains of many functional deficits, including rashes, pain and difficulty with ambulation. This is supported by the medical documentation from the referring provider. The medical documentation is sufficient to suggest that a true functional deficit is likely present. The plastic surgeon is uniquely qualified to further evaluate this patient to determine the suitability of surgical correction. However, there must be sufficient documentation to determine whether this is primarily an aesthetic or a functional procedure. Thus, greater characterization of the abnormal state is needed to support the requested procedure as reconstructive in nature or medically necessary. Based on review of the available records, the requested surgery is not reconstructive in nature and not medically necessary for treatment of the patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male has requested coverage for a past magnetic resonance imaging (MRI) of the bone marrow for evaluation of his amyloidosis.  Findings:  Two physician reviewers found that the patient has a diagnosis of amyloidosis. He has documented gastrointestinal involvement, and has received treatment with Velcade, Cytoxan, and Decadron. He is being evaluated for treatment with high-dose chemotherapy followed by autologous stem cell transplant. As part of the work-up for this procedure, he underwent bone marrow evaluation by magnetic resonance imaging (MRI). In practice, bone marrow MRI is noted for its sensitivity in detecting extent of bone marrow involvement in plasma cell dyscrasias, and is more sensitive than plain x-rays in the detection of lytic lesions of bone. Despite this, it is not clear how data provided by MRI of the marrow is clinically applicable or how it would impact clinical decision making in this patient who is to undergo a stem cell transplant. The provider asserts that the MRI was indicated to fully evaluate the status of his bone marrow disorder. He further asserts that marrow MRIs are well-established tools for staging and evaluating marrow-based disease. In the National Comprehensive Cancer Network (NCCN) guidelines, MRI is recommended in the work-up of multiple myeloma when clinically indicated as in cases where a patients symptoms suggest the presence of a bone lesion, or plasmacytoma, and plain x-rays are non-revealing. However, routine evaluation of bone marrow by MRI is not recommended by the consensus guidelines. Given the absence of a compelling clinical justification for the utility of the diagnostic procedure at issue, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for facial laser hair removal or treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that The requested services are medically necessary in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. The patient has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. This type of hair growth in a female is known as hirsutism. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders.  The requested facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the extent possible. Laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature.  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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hysterectomy and related services. Findings:  The physician reviewer found that the hysterectomy and related services were not necessary for treatment of an emergency medical condition. Hysterectomy remains the most common surgical treatment for leiomyomas. The two most common symptoms of fibroids for which women seek intervention are abnormal uterine bleeding and pelvic pressure. The most frequent type of abnormal uterine bleeding is heavy or prolonged menstrual bleeding, which frequently results in iron deficiency anemia, as demonstrated in this case. The patient presented with similar symptoms that she had last year, which included pelvic pain and vaginal bleeding. The documentation submitted for review does not support the hysterectomy was emergent. For the reasons provided, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewers determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.