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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care. Findings:  The physician reviewer found that residential treatment center services from the date of service in question, forward were not and are not medically necessary for treatment of the patients behavioral health condition. Her weight was 136.4 pounds, BMI was 24.6, and 121% of IBW. Her vital signs were stable with only mild orthostatic change in pulse and no blood pressure change on standing. There is a lack of evidence showing that she would not respond to treatment in a less intensive setting. Her ADLs were intact and her alcohol use was of a binge nature and it was not documented for what time period she had been engaging in this behavior. Her eating disorder behavior was noted to involve restricting. There was no description as to whether she was over-exercising at the time or purging. All told, as of the date of service in question, she did not require 24-hour residential staff intervention to monitor eating disorder behavior, and could have returned to the less restrictive level of care. Thus, the services at issue were not and are not medically necessary for treatment of the patients medical condition. 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 physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old male enrollee has requested residential treatment services for treatment of his substance abuse.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient was medically and psychiatrically stable. There was no suicidal/homicidal ideation or evidence that there was any danger to others. He was cognitively intact and there was no evidence of psychosis. Although not at immediate risk due to the contained environment, the patient demonstrated a pattern of inability to maintain sobriety as evidenced by his attempting to bring drugs into the facility. He actively worked on reading assignments with counselors, shared in groups, and was learning the need for help in maintaining sobriety.  He was developing recognition of triggers and learning coping skills for relapse prevention. Prior to his initial admission to this facility he was living on the streets. He was planning to discharge to live with his mother or sober living. Given his history and recent drug seeking behavior, residential level of care was appropriate and clinically indicated in order to give him the necessary boundaries and supervision to help solidify his skills in learning impulse control before stepping down to a lower level of care. As such, residential level of care was medically necessary for the days specified, after which he could be stepped down to a lower level of care. Therefore, residential treatment services provided from the time period specified were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction surgery.In this case, the patient complains of back and neck pain and has a history of a prior breast reduction. There is no report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Furthermore, while there is mention of shoulder grooving, it is not documented on physical exam or supported by photographs of the patient. Because there are less than two quality of life signs, the requested service would not be considered medically necessary according to ASPS criteria. In addition, the patients minimal resection of 400 grams per breast would be below the 22nd percentile of 764 grams per breast at a body surface area (BSA) of 2.11 and below the 5th percentile of 488 grams per breast at a BSA of 2.11. This would qualify the procedure as purely cosmetic according to weight. Combining this lack of determination of medical necessity based on weight with the lack of determination of medical necessity based on ASPS criteria, the requested breast reduction surgery is not medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient has back and neck pain, but there is no documentation that this pain is due to breast hypertrophy. Records indicate that the patient suffers from obesity, and weight loss was recommended. The patient has already undergone a breast reduction procedure and no further breast reduction is recommended for improvement in function. There is also no report in the submitted documentation that the patient does not have a normal appearance or that a breast reduction would cause more than a minimal improvement in her appearance. Accordingly, the requested breast reduction surgery is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that symptoms beyond the generally accepted time frame of two weeks for recovery of concussion is referred to as post-concussion syndrome. The mainstay of treatment for concussion and post-concussion syndrome include rest, gradual return to activities, and self-management strategies. Some rehabilitation interventions in the early setting have been shown to be effective in addressing functional concerns for this condition, but there is a lack of data to draw conclusions about the effectiveness of individualized rehabilitation for post-concussion syndrome patients. The records provided for review document chronic, persistent symptoms following remote head traumas. The patient has some subjective clinical benefit from rehabilitation efforts. Treatment has included adequate rehabilitation and education to be independent with a home exercise and self-management program. Although the patient reports ongoing symptoms, there is a lack of expectation that additional formal physical therapy will result in a marginally significant benefit over an independent program. All told, the requested physical therapy 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 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

A 46-year-old female enrollee has requested lumbar and cervical spine epidural injections for treatment of the her neck and back pain.  Findings:  The physician reviewer found that In the most recent pain management guidelines as discussed by Manchikanti and colleagues, a patient should not be blindly scheduled for a series of injections, but should receive injections based on the patients response to initial treatment. The authors suggest that subsequent injections should be done no sooner than two to four weeks after the initial treatment. Therefore, for this patients lumbar spine, one repeat epidural steroid injection (ESI) is medically indicated to determine whether further relief can be obtained and if additional therapeutic injections should be administered. In addressing the patients neck pain, the records provided poorly document previous therapies tried and failed, such as physical therapy, medications, and lifestyle modification. There is however adequate evidence of spurring and retrolisthesis at C5-6 that can cause radicular irritation. Moreover, there is documentation of neck pain with mild radiation stiffness and spasm. For these reasons, a diagnostic cervical ESI is medically appropriate as part of the patients work-up to assist in alleviation and non-surgical management of the patients condition. Only one injection should be approved as detailed above predominantly for diagnostic purposes, and subsequent injections should be approved based on the efficacy of the initial injection and the degree and length of relief. This may also be an appropriate adjunct to physical therapy for this patient, and she should be evaluated two to four weeks post injection for further treatment planning.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee requested authorization and coverage of breast reconstruction surgery for the treatment of breast asymmetry.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees delayed speech/language development.   Findings:  The physician reviewer found that there is no medical documentation provided that describes a disease, injury or congenital deformity as the cause of this patients receptive and expressive language delay. Based upon the current medical literature, a meta-analysis of treatment of language delay show some benefit in treatment. However, without an underlying medical cause, speech therapy would not typically be considered medically necessary. Expressive and receptive language delays are not uncommon in young children; in the absence of an identifiable medical condition, such delays are generally appropriately addressed through the educational system. All told, the records provided for review do not establish the medical necessity of speech therapy services for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested meniscal allograft transplantation of the knee, osteochondral autograft, arthroscopic lavage and arthroscopic debridement for the treatment of her osteoarthritis of the knee. Findings:  Two physician reviewers found that meniscal allograft transplantation is an accepted procedure for this subgroup of patients. Although long-term outcomes remain unproven, the alternatives (unicondylar knee replacement and total knee replacement) are even less well understood in the young patient. Given the severity of the patients condition, and the absence of more effective alternatives, meniscal allograft transplantation and associated procedures were an appropriate option for the patient and should be covered by the Health Plan.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested CyberKnife stereotactic radiosurgery for the treatment of her metastatic breast cancer to the lung. Findings:  Two physician reviewers found that this patients right anterior chest wall has been irradiated. This would preclude irradiating the right upper lung mass through conventional approach. Stereotactic radiosurgery would minimize the radiation to the right anterior chest and breast while treating the right upper lung mass. In this patient with metastatic cancer to the lung, CyberKnife stereotactic radiosurgery offers superior benefit and is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Coflex interlaminar stabilization device. Findings:  Two of the three physician reviewers found that the current evidence-based literature and long-term studies support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis. This patient presents with persistent and worsening low back pain radiating into the left lower extremity with numbness and tingling. She had significant functional limitations in activities of daily living. Her symptoms are consistent with imaging evidence of disc extrusion with moderate to severe subarticular and foraminal stenosis with nerve root compromise. She had failed physical therapy, medications, and activity modification. Therefore, the requested Coflex interlaminar stabilization device is likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee requested reimbursement for the computed tomography (CT) scan of the maxillofacial/sinus. There is sufficient support for the services at issue in this clinical setting. CT scanning is the standard method of evaluating the sinuses. Moreover, Che and colleagues stated, Analyzing the CT features of bone changes in unilateral chronic maxillary sinusitis can improve the accuracy of disease diagnosis. In this case, the patient has a history of shortness of breath and fatigue as well as nasal symptoms. A CT scan was obtained to evaluate the sinuses for possible infection and surgery. Therefore, the CT scan of the maxillofacial/sinus was medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 otolaryngology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Zejula 100 mg capsules (two capsules daily for one year). The U.S. Food and Drug Administration (FDA) approves the use of Zejula (generic name niraparib), a poly (ADP-ribose) polymerase (PARP) inhibitor, for the maintenance treatment of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in adults who are in a complete or partial response to platinum-based chemotherapy. The National Comprehensive Cancer Network (NCCN) guidelines for ovarian cancer note that bevacizumab may be continued as maintenance therapy until disease progression or unacceptable toxicity. Bevacizumab should be discontinued before initiating maintenance therapy with a PARP inhibitor. Niraparib should be reserved for recurrence. Mirza and colleagues note that the use of niraparib and bevacizumab for the treatment of platinum-sensitive recurrent ovarian cancer warrants further evaluation and is the subject of continued phase III trials. Given the lack of current medical evidence supporting the use of the combination of nirparib with bevacizumab for maintenance therapy in this clinical setting, the requested medication is not medically indicated. Therefore, Zejula 100 mg capsules (two capsules daily for one year) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee requested long-acting insulin, Lantus (insulin glargine) for medical treatment of his type 2 diabetes.  Findings:  The physician reviewer found that the patient has had hypoglycemia with NPH insulin and did not have this, at least to this degree, with Lantus. The patient also has CAD and has had myocardial infarction. There is particular concern about low blood sugar levels in this population of patients with known CAD. There are concerns that this might induce heart arrhythmias and possibly sudden death. In addition, recent treatment recommendations suggest relaxing the A1C goal in such patients who have had diabetes for many years and take insulin and have a history of CAD in order to avoid low blood sugar levels and hypoglycemic reactions. Thus, it is medically appropriate to avoid NPH insulin in this clinical setting. Furthermore, Lantus has been more effective for this patient in terms of overall control and frequency of hypoglycemia. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic 0.25-0.5 mg pen. The records reviewed for this patient document a history of obesity and comorbid obstructive sleep apnea (OSA). The patients provider has recommended treatment with Ozempic, given the patients limited response to treatment with phentermine. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). Given this support, the requested Ozempic 0.25-0.5 mg pen is medically necessary for treatment of this patient.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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism 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 58-year-old female enrollee has requested authorization and coverage for foot orthotics. Review of the documentation provided indicates the patient has a diffuse metatarsalgia and has been treated with Spenco polysorb inserts with some improvement. The Health Plan has denied authorization for the requested orthotics on the basis that they are not medically necessary. The Health Plans denial should be upheld. Review of the submitted documentation does not support the medical necessity for fabrication of a functional tri-plane corrective foot orthotic. There is no documentation as to the patients general foot structure and how an orthotic would be beneficial. In addition, though there is documentation of a moderate hallux abducto valgus deformity, no pain was noted with range of motion of the first metatarsophalangeal joint. Furthermore, while pain was noted in the second metatarsal no documentation has been provided demonstrating how the requested orthotic would be beneficial for the patients condition.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.