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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether for IOP services that were provided were medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that the medical records indicate the patient had limited insight into his need for treatment and he expressed suicidal ideation. The patient showed some commitment to therapy but also exhibited counterproductive behaviors including lying and producing fake signatures.  He continued to have symptoms of depression and insomnia. The medical records indicated the patient had poor judgment and insight, and demonstrated impulsive behaviors. The patient was at risk for substance use and relapse. IOP level of care includes direct services for patients with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. IOPs are alternatives to more restrictive levels of care designed to establish psychosocial support, as well as facilitate relapse management and coping strategies. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is used to determine the necessary level of care for adults. The six dimensions include risk of harm, functional status, comorbidity, recovery environment and level of support, treatment and recovery history, and engagement and recovery status. The patients composite score is 17, which correlates with an IOP level of care. The medical evidence supports the services at issue in this clinical setting. Therefore, the IOP services that were provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were 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 psychiatry with a subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for titration polysomnography. Findings:  The physician reviewer found that current diagnostic standards for obstructive sleep apnea require that a patient have an apnea-hypopnea index (AHI) or respiratory event index (REI) of at least 5.0 events per hour. In this case, the patients recorded AHI was four events per hour. This is below the diagnostic threshold for obstructive sleep apnea. This patient does not have a medical condition that would necessitate nocturnal respiratory assistance, such as severe pulmonary disease or neuromuscular disease, for which positive air pressure is used. The use of CPAP in patients who do not meet diagnostic criteria for OSA is not otherwise supported within current practice guidelines. In this setting, the requested titration polysomnography is not medically necessary for the evaluation of this patient. 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 neurology with sub-specialty certification in sleep 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone-acetaminophen 5 mg-325 mg tablets, quantity 30. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested medication quantity in this patients case. Additionally, there is no documentation of completion of physical and behavior therapy, despite much research to support their use. It is also reasonable to consider alternatives to opioids and to taper the patient to a lower dose of opioids or even off opioids. Furthermore, there are no objective treatment goals for pain and function noted for the requested medication and medication quantity. The Centers for Disease Control and Prevention (CDC) guideline states that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. When opioids are started, clinicians should prescribe the lowest effective dosage. Also, multiple minimal requirements for opioid prescribing have not been done and the need to use them as the primary medication treatment strategy for pain, in this patients case, has not been established. Finally, not all non-opioid medications classes have been optimized or tried. For all these reasons, the requested authorization and coverage for hydrocodone-acetaminophen 5 mg-325 mg tablets, quantity 30, is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication quantity is 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom orthotics. The nationally-recognized, evidence-based Official Disability Guidelines (ODG) state that both prefabricated and custom orthotic devices are recommended for plantar fasciitis. Wrobel and colleagues conducted a randomized, controlled trial of custom foot orthoses for the treatment of plantar heel pain. They concluded that custom foot orthoses demonstrated 5.6-fold greater improvements in spontaneous physical activity versus pre-fabricated orthoses or sham insole treatment for plantar fasciitis. A study concluded that there was strong evidence for the prescription of custom-made foot orthoses in painful pes cavus and for foot pain in juvenile idiopathic arthritis, rheumatoid arthritis, plantar fasciitis and hallux valgus.Here, the patient presents with worsening bilateral foot pain with associated functional mobility limitations. Signs/symptoms and clinical exam findings are consistent with plantar fasciitis. She has failed to improve despite long-term conservative treatment, including over-the-counter orthotics, shoe wear modifications, exercise, ice, massage, topical and oral NSAIDs, corticosteroid injections, and activity modification. Current evidence-based medical guidelines and literature support the use of custom foot orthotics for the treatment of plantar fasciitis in this setting. Therefore, this request for custom orthotics is medically necessary for treatment of the enrollees plantar fasciitis. Final Result: The reviewer determined that the requested items 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

The patient is a 44-year-old female who is 54 weighing 228 pounds. She is status post gastric bypass. She lost 128 pounds following the weight loss procedure but now wants further bypass surgery in order to attain a goal weight of 150 pounds. The patient is not on a clearly documented dietary restriction regimen. She has multiple medical problems, which she states prevent her from exercising, though she was provided a modified program that she has apparently not attempted. Additionally, the submitted records indicate the patient has been non-compliant in stopping her tobacco use.At issue is whether gastric bypass surgery is medically necessary for treatment of the patients medical condition. Despite nearly a 40% decline in weight with gastric bypass, the patient continues to seek passive weight loss without demonstrating any initiative on her part to lose weight. Reoperative surgery carries a substantial risk without any clear assurance of ultimate benefit. The patient would be at significant risk of malabsorption. Moreover, the patients depression seems to be a confounding factor and there is no documentation indicating the patient has undergone a psychiatric evaluation. All told, the clinical indications for gastric bypass surgery have not been met. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested for pulsed radiofrequency ablation (RFA) for treatment of her meralgia paraesthetica.   Findings:  Three physician reviewers found that standard therapy for this condition is a lateral femoral cutaneous nerve block with local anesthetic and steroid (see Grossman, et al.). Peripheral pulsed radiofrequency ablation remains unproven for this condition. There are no published articles suggesting that peripheral pulsed radiofrequency ablation is efficacious in this setting. There are other standard therapies such as surgical decompression that are likely to result in a superior outcome (Grossman, et al.).
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female has requested speech therapy for treatment of her severe expressive language impairment.  Findings:  The physician reviewer found that the patient had a profound deficit in her expressive language skills when she was tested at the age of 18 months.  The patients scores on standardized objective testing were significantly below average. The submitted documentation demonstrates the patient made significant improvements in her speech, from being a non-speaker to being only 28% delayed after 4 months of speech therapy, which confirms the validity of the effectiveness of speech therapy for speech delayed children.   The common practice of the medical community is to refer a speech-delayed child to a speech therapist to develop speech. There is a robust body of medical literature supporting speech therapy in this population. Children with speech delay can be readily treated (Law, et al.) and cognitively normal children are ideal candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). Speech therapy has been found to be efficacious in the treatment of speech delays in young children (Emmanuel, et al.). Thus, it is medically necessary and appropriate for this patient to continue to receive speech therapy. Given the patients previous gains, it is likely that she will continue to benefit from additional therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the facial feminization surgery performed. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee's gender dysphoria. At issue in this case is whether the facial feminization surgery was medically necessary for treatment of the patients gender dysphoria. The guidelines for the medical necessity of FFS exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. On the matter of medical necessity and the classification of FFS as reconstructive surgery, WPATH states that: In addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures are described in section XI of the standard of care (SOC). These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including for example skin flap hair removal; scrotoplasty; and penile and testicular prostheses, as necessary; facial hair removal; certain facial plastic reconstruction; voice therapy and/or surgery; and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The Transgender Medicine Model NCD Working Group, Transgender Law Center, in their review of evidence for FFS state that: Other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women includereconstructive facial feminization surgeryThese procedures are not cosmetic, but rather serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female.Facial feminization surgery (FFS) would provide reconstructive surgical services for an abnormality because of the disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. The patient has a documented history of gender dysphoria. Based on the documented history of gender dysphoria and evidence of the medical necessity of FFS, the requested facial feminization surgery was medically necessary. Final Result: The reviewer determined that the services at issue were 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 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 enrollee requested reimbursement for Guardant360 Comprehensive Liquid Biopsy. The enrollee began to experience persistent hemoptysis and was subsequently diagnosed with non-small cell lung cancer.  A computerized tomography (CT) scan of the chest showed bilateral disease. Biopsies revealed adenocarcinoma.  She underwent four cycles of chemotherapy.  A positron emission tomography (PET) scan showed significant disease on the right side.  She worsened clinically with increased hemoptysis. She received radiation therapy for about one year.  She started on nivolumab and docetaxel afterwards.  She underwent therapeutic thoracentesis.  A CT scan subsequently showed mild enlargement of a nonspecific right middle lobe nodule.  When she presented to her oncologist for cycle 25 of docetaxel, she complained of left-sided chest wall pain. Physical examination revealed decreased breath sounds at the left lung base. The provider found progression in the right lung after reviewing CT imaging. The physician ordered Guardant360 testing. A biopsy would be performed if the results were negative.  The testing revealed no tumor-related somatic alterations.The Guardant360 is a blood-based liquid biopsy approach that analyzes circulating tumor DNA (ctDNA) and searches for actionable genetic mutations. This test is still in the research phase and has not become the standard of care to replace or precede tissue biopsy. There are no ongoing studies of the Guardant360 test specifically in stage IV lung cancer. To date, there is insufficient literature to support that liquid biopsy is as effective as tissue biopsy to be used to determine patients lung cancer diagnosis, prognosis and treatment therapy. Currently, there is ongoing research to advance the liquid biopsy assays and enhance its utility in molecular diagnostics and precision medicine for lung cancer. While liquid biopsy may replace tissue biopsy in the near future, it is not currently supported by literature and current guidelines to replace tissue biopsy as means of guiding cancer diagnosis. Final Result: Three of the three reviewers determined that the requested services were not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Medical Oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee who has been diagnosed with alcohol use disorder and depression. He reported drinking 10 drinks per day during the week prior to presenting for treatment. The records noted that the patient consumed six to eight drinks per day prior to that at baseline. He reported a history of blackouts. The patient began an intensive outpatient program (IOP), relapsing during the program. His medications included Zoloft.  The patient has requested reimbursement for residential treatment center services that were provided from. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The American Psychiatric Association treatment guidelines indicate that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The patient required a safe and stable living environment in order to develop his recovery skills. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness with regular blackouts, his risk factors in relationship stress and stressors, such as loss of parent, residential treatment was in accordance with generally accepted standards of medical practice. Therefore, the requested residential treatment center services provided were medically necessary.Final Result: The reviewer determined that the requested services were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued skilled nursing level of care including physical therapy and wound care. At issue is whether the requested continued skilled nursing level of care including physical therapy and wound care is medically necessary for treatment of this patient. Acute heart failure has multiple potential etiologies, but typically occurs in the setting of decompensation of a pre-existing cardiomyopathy (Abdo). Statins are generally safe and highly effective pharmacotherapeutic tools used in the management of dyslipidemia to reduce cardiovascular morbidity. Statin-induced myopathy is the most common cause for discontinuation of this therapy (Ward, et al.; Vinci, et al.). Treatment in this clinical setting starts with statin discontinuation, consideration of re-challenge therapy with a different statin, and possible treatment with non-statin lipid lowering pharmaceuticals. In some cases, myopathy can persist despite statin discontinuation (Meyer, et al.). The patient in this case reportedly developed severe cardiomyopathy, most likely due to myocarditis. The patients ejection fraction was 15% initially and improved to only 20%. He also developed severe weakness in his left leg, attributed to statin-induced myopathy. The statin was discontinued, but there is a lack of documentation that the patient has experienced significant recovery of motor function in the affected limb. The patient has required a left knee and left ankle foot orthoses to stabilize his leg for standing and limited walking in the parallel bars. Overall, the patient has essentially maximized the amount of function he is expected to gain given his underlying impairments affecting his heart and his left lower limb. The patient is not expected to become a functional ambulator in the near term despite additional physical therapy. The patient will continue to require significant assistance to manage his lower body self-care. However, the records do not report ongoing skilled rehabilitation or skilled nursing needs requiring further SNF level care. For these reasons, the requested continued skilled nursing level of care including physical therapy and wound care 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: Upheld

A 60-year-old female enrollee, who has had a history of intermittent, incapacitating pain which radiates from the back to the anterior abdomen, has authorization for MRI of the thoracic and lumbar spine.Findings:  The physician reviewer found that the reason given for the MRI of the thoracic and lumbar spine was to rule out possible nerve entrapment or neuroma, based on the patients sensory myelopathy and radiculopathy. However, there is no comprehensive neurological examination included in the record. A prior MRI of the lumbar spine showed no masses. Evaluation by a neurologist may have been helpful at this juncture, prior to additional imaging.