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

A 28-year-old female has requested a wheelchair for treatment of her morbid obesity.   Findings:  The physician reviewer found that the records provided for review do not document any significant impairment to the cardiovascular system, pulmonary system, neurological system or other relevant organ systems. Overall, there is no evidence of any significant impairment of mobility that require a wheelchair. Further, the records fail to demonstrate that use of a wheelchair would be beneficial to the patient. As far as the records describe, the patient is able to walk either with or without an assistive device such as a cane, walker or Rollator. However, the records do not establish that a manual or power wheelchair is required by the patient to accomplish her mobility-related activities of daily living. The request for a wheelchair for this patient at this time does not meet Medicare or other relevant clinical guidelines for medical necessity. Moreover, the patient needs to remain as physically active as possible in order to reduce or maintain her weight, as well as to improve or at least maintain, her current level of function.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male has requested  applied behavioral analysis (ABA) therapy at home and at school for treatment of his attention deficit hyperactivity disorder (ADHD) and disruptive behavior, not otherwise specified (NOS). Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments for those who are diagnosed with autism. Behavioral therapy for ADHD and oppositional behaviors is supported by evidence-based research and is better than placebo (Prock, et al). This behavioral therapy does not follow the principles of the Lovaas technique, rather behavior modification which consists of a point/token reward system (Prock, et al). Ongoing psychological strategies and therapy is recommended for this young patient. However, ABA therapy is not medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospitalization services.The submitted documentation supports that the services at issue were medically necessary. Atypical symptoms of ischemia can be the presenting signs of an acute coronary syndrome in women (Jones, E., et al.). Diabetes mellitus is a significant cause of death and disability worldwide and is a strong risk factor for acute coronary syndrome (ACS). The excess risk of ACS associated with diabetes is significantly higher in women than in men (Dong, X., et al.). In this case, the patient has a history of diabetes and presented with both typical and atypical symptoms of ischemia. The patient also had an abnormal electrocardiogram (EKG) and was appropriately admitted for a possible acute coronary syndrome. After the patient was ruled out of myocardial infarction (MI), a stress test was done that was negative for ischemia, and telemetry monitoring revealed paroxysmal atrial fibrillation that correlated with the patients symptoms. Based on the patients presenting complaints, her elevated pre-test probability of coronary artery disease (CAD) due to age and diabetes, and her abnormal baseline EKG, her inpatient hospital admission and the guideline directed medical therapy and evaluation that she received for unstable ischemic heart disease (which was eventually ruled out) was medically necessary and appropriate. The patients diabetes also put her at increased risk for a poor outcome if this had been an ischemic syndrome. Under these circumstances, the hospitalization services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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 cardiovascular disease, 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 patient has requested authorization and coverage for Xifaxan 2250 mg. Pittman and colleagues note that almost all patients with systemic sclerosis have gastrointestinal manifestations, including small intestinal bacterial overgrowth (SIBO). Polkowska-Pruszynska and colleagues report that SIBO remains a diagnostic and therapeutic challenge and is a significant clinical problem among patients suffering from systemic sclerosis. According to Gatta and Scarpignato, rifaximin (brand name Xifaxan) treatment is effective and safe for the treatment of SIBO. Barkin and colleagues note that rifaximin is the most commonly prescribed antibiotic regimen for SIBO therapy. The dose and duration of 550 mg three times daily for 14 days is consistent with regimens used in current medical literature. In this case, the patient has a diagnosis of scleroderma with symptoms consistent with SIBO. In this clinical setting, given the risk of and prevalence of SIBO in patients with scleroderma, the requested medication is medically indicated. Therefore, Xifaxan 550 mg is medically necessary for the 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 sub-specialty certification in gastroenterology 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

Enrollee has requested authorization and coverage for annual breast magnetic resonance imaging (MRI). As noted by the American College of Radiology (ACR) and the National Imaging Associates (NIA), mammography is the recommended method of breast cancer screening in the general population. However, for patients with dense breast parenchyma, the current data suggests that MRI is considered the most sensitive modality for breast cancer screening. This patient was found to have breast cancer at an early age, and the tumor was occult on mammography due to underlying dense breast tissue. She is at risk for recurrence due to her age at the time of initial diagnosis of breast cancer and mammography is of limited value due to dense breast parenchyma. Thus, the requested annual breast MRI is supported as medically necessary for evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 patient has requested authorization and coverage for revision shoulder surgery to reconstruct a grade 5 acromioclavicular (AC) joint separation using a technique that uses a combination of polyester tape (Lockdown) and a distal clavicle hook plate (Synthes). Researchers noted that coracoclavicular ligament reconstruction by autologous plantaris tendon or allogeneic tendon graft combined with hook plate fixation for the treatment of acromioclavicular joint dislocation can achieve good effectiveness. Researchers found higher complication rates with loop suspensory fixation when compared to hook plating. In this case, the patients grade 5 AC separation was repaired with a coracoclavicular suture fixation that came apart with recurrent trauma. Due to the chronic nature of the separation, maximum fixation using both acromioclavicular and coracoclavicular will be necessary to compensate for the slow healing reaction and prevent disruption. As such, the requested services are medically indicated. Therefore, revision shoulder surgery to reconstruct a grade 5 AC joint separation using a technique that uses a combination of polyester tape (Lockdown) and a distal clavicle hook plate (Synthes) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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

The parent of a three-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 patient due to his history of severe expressive and receptive speech delays and socialization deficits associated with autism spectrum disorder. In the peer reviewed medical literature, Rogers and Vismara reviewed the available published studies for evidence supporting the efficacy of early intervention for young children with autism. The authors reported significant increases in language and communication abilities occurred in patients who received intervention with speech therapy over patients who were untreated. Further, Green and colleagues discussed the guidelines provided by the National Research Council which states that, Building spontaneous functional communication skills as a core aspect of effective treatment for children with autism at all ages and levels of disability. Overall, the authors concluded that speech therapy is the most commonly reported intervention for children with autism noted in an internet survey of over 552 patients diagnosed with autism. Moreover, a study by Stone and Yoder evaluated 34 children at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. After controlling for age, the only significant predictors were motor imitation and number of hours of speech and language therapy. With regard to this patient, he also presents with significant hypotonia and drooling that may indicate a disorder involving congenital myopathies. Strober indicated that facial weakness and dysarthria are clinical features of congenital myopathies. Given this additional muscle weakness and medical problem, appropriate speech therapy is further shown to be medically necessary for adequately addressing this patients communications deficits secondary to autism.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for brain surgery for treatment of her meningioma. Findings:  The physician reviewer found that there has not been any specific medical issue raised that would necessitate treatment at UCSF Medical Center. I see no clinical indication for an out-of network referral in this instance.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for emergency medical services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The emergency medical services provided from  were necessary for treatment of an emergency medical condition. In this case, the patient presented in active labor with full cervical dilation. Given that the fetus was in a breech presentation, cesarean delivery was appropriate. Moreover, it would not have been medically safe to transfer her to another hospital. For the reasons provided, the emergency medical services provided meet criteria for emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for weekly occupational therapy (as opposed to occupational therapy every other week). The American Academy of Pediatrics (AAP) describe that, Children with ASD may have low muscle tone or a developmental coordination disorder. The AAP noted that, Occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. Monz and colleagues noted that, The American Academy of Child and Adolescent Psychiatry recommends the use of multiple treatment modalities in ASD. Although occupational therapy is generally accepted for the treatment of patients with ASD, evidence is lacking in the published literature to support optimal intensity and dosage of occupational therapy for children. Gee and colleagues published a meta-analysis evaluating the available studies on occupational therapy for children with ASD. The authors found that, evidence is lacking within the published literature to adequately guide occupational therapy dosage decisions. Further research related to dosage in pediatric occupational therapy practice is needed. At present, there is inadequate evidence to support that one session of occupational therapy per week in lieu of one session every two weeks for treatment of this patient. Reports provided by the patients provider indicate that the patient was at an age-appropriate level on the Pediatric Evaluation of Disability Inventory (PEDI). The patient was making progress with goals with the current treatment plan. Moreover, the requested occupational therapy every week is not medically necessary to treat the patients condition or to prevent disease, disability and other health conditions or their progression, to prolong life, to promote physical and mental health and efficiency, or to correct or ameliorate any physical or behavioral conditions. All told, the requested weekly occupational therapy (as opposed to occupational therapy every other week) 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.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage, and reimbursement, for inpatient hospitalization services. The enrollee has a history of major depression, recurrent, severe, and anorexia nervosa. The enrollee reports residential and outpatient treatment in the past. She entered the inpatient level of care for treatment of her eating disorder. She reported struggling with anxiety and panic attacks, and admitted to daily use of marijuana. She reported purging five to six times per day. The enrollees provider reports the enrollee required around-the-clock monitoring for safety and for proper nutritional intake. This enrollee met criteria for inpatient level of care. Her ideal body weight was significantly below 85 percent, and continued to decline. She has comorbid psychiatric disorders, suicidal ideation and ongoing self-injurious behaviors. Due to multiple daily purging episodes, she requires supervision during and after meals. Considering her relationship with parents and lack of friends, she does not have a good support system.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee is requesting prescriptions for Sovaldi and Daklinza for the treatment of his hepatitis C infection. Findings:  The physician reviewer found that according to 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 should be treated except those with life expectancy of less than 12 months due to non-liver related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks regardless of interferon eligibility. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al).  This regimen avoids interferon-related side effects. The guidelines cite data reporting that delay in treatment may result in decreased survival (Jezequel, et al). Final Result: The reviewer determined that the requested medications 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 gastroenterology 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 authorization and coverage for Rituxan. There are several standard treatments for systemic lupus erythematosus that are steroid sparing agents permitting the safe discontinuation of chronic steroid use, including azathioprine, CellCept, Benlysta, and Saphnelo. Al-Adhoubi and Bystrom note that rituximab may sometimes be used for the treatment of disease manifestations such as refractory lupus nephritis or in the setting of diffuse alveolar hemorrhage due to systemic lupus erythematosus. However, in this case, the submitted records do not demonstrate that the patient has refractory lupus nephritis or active alveolar hemorrhage. Notes indicated that the patients systemic lupus erythematosus was clinically stable. The records do not document that the patient had tried and failed, or a reason why the patient had not been treated with, standard treatments other than hydroxychloroquine. The records noted concern regarding persistently elevated antiphospholipid antibodies including lupus anticoagulant and cardiolipin antibodies. Researchers found that patients with antiphospholipid syndrome should be treated with anticoagulants, corticosteroids, and possibly plasma exchange, and that in cases of catastrophic antiphospholipid syndrome, new therapies such as rituximab may be options but require further study. In this case, the submitted documentation did not indicate that the patient was experiencing active catastrophic antiphospholipid antibody syndrome. Rituximab may be used to treat rheumatoid arthritis; however, the records do not indicate the patient has refractory inflammatory arthritis secondary to systemic lupus erythematosus that has failed to respond to standard therapy. An examination did not reveal synovitis or bone tenderness. In the treatment of moderately-to-severely active systemic lupus erythematosus, there is a lack of data in current medical literature supporting the efficacy of rituximab. Therefore, Rituxan is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 rheumatology 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

A 63-year-old male enrollee has requested skilled nursing facility (SNF) services for treatment of his medical condition status post left femur status post intramedullary nailing removal.  Findings:  The physician reviewer found that the records indicate that he is able to walk 250 feet and is able to move from bed to chair and stand from chair with hands on assistance. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, in the absence of daily skilled therapy needs, SNF services are not considered medically necessary. A patient who does not require hands on support for walking or transfers is able to do daily exercise without support from a therapist. There is no expectation that this patients course of rehabilitation will change as his surgical procedure was uncomplicated as was his rehabilitation thus far (Ward, et al). The patient had reached a level of function that did not require daily skilled therapy to restore or maintain function. Continued progress can be achieved with continued exercise without daily supervision from a skilled therapist. Further, there were no daily skilled nursing needs. Daily skilled services are not necessary to restore or maintain function. The patient did not require SNF services to establish a safe and effective maintenance program. For these reasons, the SNF services provided from the dates indicated were not medically necessary for treatment of this patients medical condition.