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

The enrollee is requesting reimbursement for intensive outpatient program (IOP) level of care services. The enrollee has diagnoses of severe generalized anxiety disorder, obsessive compulsive disorder, major depressive disorder, autism spectrum disorder, rule out eating disorder, and rule out personality disorder. The enrollee was admitted to the intensive outpatient program level of care due to obsessive compulsive disorder and eating issues that caused her to have a low body mass index. She was admitted with the stipulation that she would gain weight while in treatment or be transferred to a higher level of care. The enrollee engaged in obsessive compulsive disorder treatment faithfully and made moderate improvements over the first month. Her mood improved. She interacted with staff and she was engaged in the program. She had a significant backslide following a family session. The enrollee had difficulty with eating due to her severe anxiety. Her weight and body mass index dropped to the threshold of what the facility could allow before transferring to a higher level of care. She experienced medication side effects and acid reflux. Her weight dropped; resulting in a body mass index below 16. She was subsequently transferred to a higher level of care. This enrollee was diagnosed with superior mesenteric artery syndrome and underwent surgery. While in the intensive outpatient program, she was seen weekly by psychiatrist. She did not have suicidal ideations or self-harming behaviors. She did not report psychotic symptoms. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations and was used in this review. The enrollees composite LOCUS score correlates with an intensive outpatient program level of care. Medical evidence supports the services at issue in this clinical setting. The enrollee had lost a significant amount of weight by the final day of service, and she had dropped to 75 percent of her ideal body weight, which necessitated a transfer to a higher level of care.Final Result: The reviewer determined that the requested services were partially 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: Upheld

The patient is a 28-year-old female who has requested authorization for evaluation by a cardiothoracic surgeon for treatment of thoracoscopic sympathectomy. There is no documented evidence the patient has attempted conservative treatment. The Health Plan has denied coverage for the requested consultation on the basis it is not medically necessary for treatment of the patients medical condition.There is no evidence of medical necessity for referral to a cardiothoracic surgeon for evaluation at this point. There is no objective evidence of trial and failure of conservative measures in this case. The patient should explore and try all non-operative measures to see if any of these modalities will provide effective treatment before pursuing invasive operative procedures. Therefore, I have recommend that the requested consultation is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-year-old female enrollee has for referral to a pediatric gynecologist for treatment of her vaginal bleeding. Findings:  The physician reviewer found that trauma and infection, two common reasons for prepubertal vaginal bleeding, have been ruled out.  A pediatric endocrinologist was consulted and concluded the patient does not have precocious puberty.  There is no medical necessity for a pediatric gynecologist, as this is a not a widely-recognized specialty.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested Botox injections for treatment of her intractable migraine headaches.   Findings:  Two physician reviewers found that the patient has been diagnosed with chronic migraine, and tried and failed prior preventives. To date, the use of Botox for treatment of patients with chronic migraine has been evaluated in phase 3 studies. The patients were treated with 155-195 Units and showed definitive statistical and clinical benefits in terms of reduction in of headache days in comparison to placebo. A responder rate of nearly 70% was seen in Botox treated patients. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives (typically about 50%), suggesting that Botox may in fact be more effective than standard preventives even in patients who have not tried and failed standard therapies. Thus, there is adequate evidence that Botox is more beneficial than placebo, and is clinically beneficial in the majority of patients. Moreover, based on 2 phase 3 trials, the Food and Drug Administration (FDA) has approved Botox as a chronic migraine preventive therapy, at dosing of 155 Units. Of import is that there are no other FDA approved medications for chronic migraine. As Botox is FDA approved for the indication of chronic migraine, it is not experimental. Therefore, Botox should be approved as per the providers treatment plan.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested fetal gene testing for medical evaluation of her recurrent miscarriages. Findings:  Two physician reviewers found that according to the American Society for Reproductive Medicine, while early miscarriage is associated with random chromosomal abnormalities in the embryo in up to 60% of cases, inherited genetic causes occur in less than 5% of couples. The standard testing is karyotype of the fetal tissue. The American College of Obstetricians and Gynecologists (ACOG) reports that limited data are available on the clinical utility of chromosomal microarray analysis to evaluate first-trimester and second-trimester pregnancy losses. Thus, fetal gene testing is not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old woman who has been diagnosed as having large vestibular aqueduct syndrome with bilateral hearing loss and vertigo. The submitted information indicates the patient has had difficulty with vertigo and hearing loss since she was a young child. In June 2003, the vertigo worsened. The patient was initially diagnosed as having Menieres syndrome and was prescribed meclizine and Diazide, as well as Amoxicillin, Flonase, and Sudafed. She did not improve and was referred to a neurologist for further evaluation. Through this evaluation a CT of the temporal bones revealed the presence of enlarged vestibular aqueducts bilaterally. Valium was prescribed for control of vertigo. Audiometric evaluation reveals bilateral severe to profound hearing loss, somewhat worse for the left ear. However, speech discrimination for the right ear was found to be 95% while that for the left scored 35%. The patient has requested authorization for cochlear implantation to help with her problem of vertigo. The Health Plan has denied authorization for cochlear implantation on the basis that it is not medically indicted based upon the patients hearing/discrimination level.Current standards for adult cochlear implantation dictate that this procedure is medically necessary and useful to patients with bilateral profound loss of hearing and poor aided speech discrimination. In September 2003, the patients provider indicated that the request for implantation of the patients left ear was made for the purpose of improving aided communication. Although this patient may become a candidate for cochlear implantation with progression of her disease, the procedure is not currently indicated given the patients discrimination scores of 95% and 35% for the right and left ears respectively. Furthermore, cochlear implantation is not medically indicated for the purpose of treating/curing vertigo. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested i-limb prostheses by Norell Prosthetics for treatment of her quadrilateral amputations secondary to gangrene.  Findings:  The physician reviewer found that this patient does appear motivated to learn and adapt to the use of functional prostheses given her current state of dependence without prostheses. Treatment options include bilateral myoelectric prostheses, a myoelectric and body-powered prosthesis, or combinations that include hybrid prostheses (Behrend, et al). The records indicate the patient has either been provided upper limb prostheses that were malfunctioning, or she had a suboptimal therapeutic relationship with her treating providers. Functioning upper limb prostheses are appropriate and necessary for this patient to perform her basic activities of daily living. While some level of cosmesis is beneficial, optimizing function is the primary concern, especially since she is dependent for her care. However, there is inadequate published clinical literature demonstrating that myoelectric prostheses with i-limb terminal devices confer significant, marginal functional benefit in comparison to conventional myoelectric prostheses that are properly fitted for an individual patient. Further, the i-limb prostheses are expected to be less durable than a conventional body-powered or myoelectric prosthesis. For these reasons, the requested i-limb prostheses are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a 19-day inpatient comprehensive multidisciplinary (including medical director, psychologist, registered dietician, and speech therapist) specialized feeding program. Pediatric feeding disorders involve severe disruptions in nutritional and caloric intake exceeding ordinary variations in hunger, food preference, and interest in eating. Young patients with feeding disorders also may have impaired cognitive and emotional development as well as compromised immune functioning. Expert consensus increasingly recognizes intensive multidisciplinary intervention at day hospital programs and inpatient settings as the standard of care for children with complex feeding problems. This level of support allows monitoring for potential complications including aspiration, severe weight loss, and allergic reactions associated with the introduction of new food types and textures, advancement of oral volumes, and reduction of enteral nutrition among children with little or no experience eating. In this case, the patient has participated in aggressive outpatient therapy for several years without discernible progress. Given the presence of his nutritional deficiencies, failure to thrive, and sensory difficulties, an inpatient feeding therapy program is the next logical treatment option. Therefore, the requested 19-day inpatient comprehensive multidisciplinary (including medical director, psychologist, registered dietician, and speech therapist) specialized feeding program is medically necessary for treatment of this patient.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 subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 55-year-old female with a history of significant back pain. She underwent a course of conservative treatment without relief. Eventually the patient underwent sacroiliac joint injection/arthrography in August 2005. The patient achieved good results from the procedure with alleviation of her pain. She is seeking reimbursement for the cost of the procedure from the Health Plan.Sacroiliac joint injection/arthrography was a clinically appropriate and indicated procedure for this patient. She had attempted a course of conservative treatment including home exercises, medication and rest. It was not until the sacroiliac injection was performed that she experienced any relief of her pain. As such, the procedure at issue was medically reasonable in this setting. Accordingly, I have determined the procedure at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injections. The Health Plan has denied this request as investigational for treatment of the enrollees condition. Findings:  Current evidence based medical literature suggests that platelet rich plasma is promising for rotator cuff and distal biceps tendinopathy. However, there is an absence of large well-designed clinical studies to support the safety and efficacy of platelet rich plasma in this patients clinical setting. Recent literature concluded that further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis. One study conducted a randomized controlled trial with one-year follow-up and concluded that platelet rich plasma injection was no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic rotator cuff tear who were treated with an exercise program. Another study conducted a systematic review and concluded that there is no solid scientific and/or clinical evidence supporting the use of PRP in the treatment of rotator cuff pathology in routine clinical practice.Final Result: Two of the three 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/QualificationsAll three reviewers 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested facial feminization surgery for treatment of her medical condition.  Findings: The physician reviewer found that with regard to whether the proposed procedure meets reconstructive surgery criteria, the patient presents with age-related changes of volume loss and loss of skin laxity of the face. There is a lack of evidence that the patients facial appearance is abnormal for a female. The requested procedure is not being performed to create a normal appearance as the patients facial features are normal for a female. In addition, the requested surgery does not offer more than a minimal improvement in the patients appearance as she would likely respond to facial rejuvenation and volumization, but not facial feminization surgery. Therefore, the requested surgery does not meet the reconstructive surgery criteria.  Final Result:  The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The physician 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: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested for Botox injections for treatment of his pain.  Findings:  Two physician reviewers found that there is documented failure of more traditional conservative care and failure of traditional trigger point injection. Botox use is supported in the literature for the treatment of spastic pain due to piriformis syndrome. This is used as a standard of care treatment in refractory cases.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested a referral for annual follow-up visits at a liver transplant clinic for his post-transplant care.  Findings:  The physician reviewer found that based on the clinical evidence provided, the patient should be authorized for annual follow-up visits at UCLAs liver transplant clinic until he reaches the age of 18. Most transplant centers of excellence would consider standard of care/mandate their transplant patients to see them at least on an annual visit and it is appropriate for the patient to continue to be followed at UCLAs liver transplant clinic for purposes of continuity of care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee requested digital breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that this patient has dense breasts and a family history of breast cancer.  Per the current medical evidence, she is an optimal candidate for breast tomosynthesis.  Therefore, digital breast tomosynthesis was likely to have been more effective than other alternatives for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment services for treatment of his binge eating disorder.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although the patient has a significant eating disorder with psychiatric comorbidity and concerning medical sequelae, the clinical documentation provided simply does not support the medical necessity of residential treatment services.  This patients pathological eating habits and subsequent obesity have been dominating his routine and impacting his sense of self and physical health.  However, he has reasonable insight and concern for his health.  The records indicate that the patient has good family support.  He successfully lost significant weight in the past when he was adherent to a meal plan.  He has not failed coordinated, multi-disciplinary specialty programming in an intermediate setting.  Finally, the record was inconsistent with an impairing psychiatric illness burden that would necessitate residential treatment.  All told, the requested residential treatment services are not medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the GeneSight Drug-Gene testing. Pharmacogenetically-guided dosing is supported in the medical litearture for use in pediatric oncology and gastroenterology as well as to guide clinical decision making for psychotropic medications based on the Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. In the clinical reviews, there is limited data demonstrating improved patient health outcomes when treatment is directed by genetic testing. In a recent review article, the authors determined that there were not enough genetic, pharmacogenetic and biochemical studies of ADHD in adults andmore investigations are needed. Ultimately, more research is needed to understand the contributions of pharmacogenomics testing in the clinical treatment of children and adolescents. Given these findings, the GeneSight Drug-Gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the GeneSight Drug-Gene testing that was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the GeneSight Drug-Gene testing that was was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics, neurodevelopmental behavioral pediatrics, and genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and clinical cytogenetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics and genetics and is 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.