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

A 52-year-old female enrollee has requested for Amrix 15mg for treatment of her headaches, neck pain and muscle spasms. Findings:  The physician reviewer found that this patients more severe headaches with nausea and vomiting most likely represent migraine. Triptans are within the standard of care in this setting if not medically contraindicated. Migraine preventive medications such as a tricyclic antidepressant are also well-accepted in this setting. The patient found Amrix to be helpful and cyclobenzaprine 10mg was too sedating. However, there is no indication that cyclobenzaprine 5mg has been tried. A lower dose of cyclobenzaprine may reduce drowsiness. Amrix has not been shown to be more effective than generic cyclobenzaprine.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hip arthroscopy with labral repair, acetabuloplasty and femoroplasty. Findings:  The physician reviewer found that femoroacetabular impingement results from bony morphologic abnormalities of the hip joint that result in abnormal contact during motion. Patients with femoroacetabular impingement present with chronic, deep, or aching anterior groin pain most commonly in the sitting position, or during or after activity. Patients might also experience occasional sharp pains during activity. Diagnosis of femoroacetabular impingement should be confirmed with radiography. Femoroacetabular impingement can be managed conservatively with rest, modification of activities, medications, and physiotherapy, or with surgical intervention. Recent developments in hip arthroscopy have facilitated a minimally invasive approach to the management of femoroacetabular impingement with few complications. Acetabular labral preservation and repair has been shown to provide superior results when compared with debridement alone.The records provided for review support a diagnosis of femoroacetabular impingement and labral tear. The patient has persistent mechanical symptoms, physical findings of hip tenderness, pain on extremes of motion, and positive anterior hip impingement test. The patients symptoms of chronic aching anterior groin pain are consistent with femoroacetabular impingement. In addition, MRI revealed a labral tear which extends from the 9 oclock to the 3 oclock position, which correlates with the patients known injury. Although she has evidence of osteoarthritis, the provider noted that there is sufficient joint space for a salvage procedure including acetabuloplasty, labral repair, and femoroplasty. Overall, the records establish the patients chronic left hip pain has failed to improve despite adequate conservative treatment including rest, anti-inflammatory medications, physical therapy, and injections. In light of the foregoing, the requested hip arthroscopy with labral repair, acetabuloplasty and femoroplasty is medically necessary for treatment of this patients left hip pain.Final Result: The reviewer determined that the requested surgery 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: Experimental/Investigational
Decision: Overturned

The parent of a male enrollee requested an intensive inpatient feeding program (with a one year authorization period) for medical treatment of the enrollees feeding problem.  Findings:  Two physician reviewers found that  the patient has severe feeding aversions as well as gagging with certain foods and vomiting. He has tried outpatient therapy which has not advanced his ability to take foods by mouth. Inpatient feeding programs have been shown to be successful in patients such as this that have not responded to other therapies. Therefore, an intensive inpatient feeding program (with a one year authorization period) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 53-year-old female enrollee has requested continued skilled nursing facility services for treatment of the enrollees multiple medical problems. Findings:  The physician reviewer found that the submitted clinical information demonstrates the patient is not a candidate for skilled rehabilitation services as she cannot progress and such services are not necessary to prevent decline. Though range of motion activity is needed to prevent decline, skilled rehabilitation is not. However, the patient has a PEG tube and receives 1800 calories per day via PEG as well as hydration and medication. The reliance on PEG feeds to maintain total nutrition constitutes a skilled nursing service as defined by Medicare regulations. Thus, the patients medical condition and nursing needs are consistent with generally accepted standards of care for skilled nursing.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. This patients sister was diagnosed with breast cancer. However, the records indicate that the sister underwent BRCA1 and BRCA2 testing, which was negative. Thus, BRCA1 and BRCA2 testing were not indicated in this patients case. Per the submitted documentation, this patient was evaluated with further gene testing for PTEN and a panel of genetic mutations. Although these other genes are of interest, they have as yet not been found to be significant enough to be the basis for clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from major organizations. Therefore, genetic testing performed was not likely to have been of superior over other methods of evaluating this patient. Final Result: 2 of 3 reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All 3 Physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

The patient is a 53-year-old obese female who is 277 pounds and has bilateral varicose veins that are painful. On duplex, she has mild reflux of the saphenofemoral junction on the right, and no other reflux on the left side. Her varices seem to be equally distributed between both legs. The patient indicates she is symptomatic. Use of compression stockings has been recommended. The patient has requested authorization and coverage for vein stripping or injections (sclerotherapy). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients varicose veins.The duplex findings demonstrate only mild reflux on the right side. Performing vein stripping on the right side will not have any effect on the patients symptoms. Furthermore, with regard to the patients request for injections or sclerotherapy, the submitted documentation does not demonstrate the patient has undergone a three to six month trial of conservative management. Conservative management should involve compression stocking use and continued weight loss. Moreover, the submitted documentation does not indicate the size of the veins; treatment of veins less than 1-2 mm is generally considered cosmetic. Lastly, if GSV reflux is to be treated, the duration of reflux on duplex needs to be documented, as minimal reflux with the Valsalva maneuver is considered normal and does not require intervention. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc I for treatment of the enrollees left knee pain. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of viscosupplementation (Synvisc) injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective. Moreover, this may allow for delay of total knee replacement, and these injections are more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of the left knee. She has worsening left knee pain and functional impairment in mobility that have failed to respond adequately to other conservative treatments. Therefore, the requested Synvisc I injections to the left knee are 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 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 2-year-old male enrollee has requested group speech and language therapy 3 days per week, for 2 hours per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the request for speech and language therapy is medically necessary despite the absence of documentation of any laryngeal pathology or oromotor anatomical anomalies. The patients speech and language testing with the RITLS and DAYC revealed significant impairments in expressive and pragmatic skills as well as borderline delays in receptive language. As such, this patient presents with a diagnosis of speech and language delay supported by clear documentation of receptive and expressive language delay. As demonstrated in the medical literature, abnormal language development can be improved through speech therapy given the plasticity of the young patients developing brain. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. In addition, the requested frequency of three sessions per week is clinically indicated as recommended by the treating provider. For these reasons, the requested speech therapy services are medically necessary based on an overall evaluation of the relevant medical literature.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested Lyrica for treatment of her migraine. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been diagnosed with migraine, and this has not been responsive to triptans.  Based upon the medical records, she has had a trial of one tricyclic antidepressant.  However, she has not had a trial of standard seizure category preventives, such as Topamax or Depakote, or beta blockers, for which there is strong support.  The medical documentation does not demonstrate that standard, commonly effective preventive medications have been tried in this patients case.  All told, Lyrica is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cooling device durable medical equipment (DME) for treatment of the enrollees anterior cruciate ligament (ACL) tear. Findings: Two of the three physician reviewers found that in one medical literature, they concluded that the limited evidence available is insufficient to draw definitive conclusions on the effectiveness of cryotherapy for outcomes other than reduction in pain 48 hours after surgery. The study noted that there is a need for well designed, good quality randomized trials to answer other questions related to this intervention and increase the precision of future systematic reviews. Another study found that patients using a temperature controlled continuous cold flow device showed significantly better results the first post-operative day. The authors reported that further studies with higher number of patients and longer follow-up are required to assess the beneficial effects on rehabilitation of the routine use of this device. This patient was scheduled for left ACL reconstruction surgery with allograft. A water circulation cold pad with pump was recommended for post-surgical cold therapy. Overall, there is a lack of large volume long-term studies evidencing significant overall outcome differences with regards to continuous flow cryotherapy versus standard cold packs in ACL reconstruction surgery, especially with allograft. Final Result: The reviewers determined that the device at issue was 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: 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: Upheld

The patient is a one-year-old twin who was born 10 weeks premature followed by a two month NICU admission. The patients parents are requesting authorization for Synagis injections for the winter months. This request has been denied by the Health Plan. The patient does not meet the nationally accepted guidelines for consideration of Synagis. Specifically, the American Academy of Pediatrics recommends Synagis before the start of the RSV season for premature infants born at 29-32 weeks who are under six months of age. Although this patient was born premature, he is not under six months of age. In addition, the patient does not meet other qualifying criteria for consideration of Synagis. Therefore, Synagis is not recommended for this patient. Accordingly, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services and reimbursement and prospective authorization and coverage for intensive outpatient program services. The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment or similar care higher than outpatient 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 useand wholack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this case the patient required a safe and stable living environment in order to develop recovery skills thus qualifying for ASAM American Society of Addition Medicine Level 3.1 treatment at least. This level of care is similar to what the patient received. While detoxification is provided to make a patient physically stable and safe rehabilitation is the essential component that should follow detoxification to help a patient maintain sobriety and reduce risk of relapse. Given the severity of this patients illness and his high risk of relapse residential treatment center services were in accordance with generally accepted standards of medical practice as evidenced by the American Psychiatric Association guidelines and American Society of Addiction Medicine criteria. Residential treatment was also clinically appropriate for the patients illness and was therefore medically necessary. The American Psychiatric Association treatment guidelines for substance use disorders also note that IOP can be used as step-down programs for individuals leaving hospital or residential settings who are at a high risk of relapsing or to stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. IOP services are classified as ASAM Level 2.1 treatment which encompasses services that are capable of meeting the complex needs of people with addiction and co-occurring conditions like this patient with opioid use disorder MDD and PTSD. In this case IOP treatment was and is in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Therefore the IOP services provided to the patient were and are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue and requested services were and 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 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 reimbursement for the inpatient mental health treatment services provided. Findings:  The physician reviewer found that due to the fact that the patient was no longer suicidal and was cooperative in treatment, the patient was a candidate for treatment in a less restrictive setting for the dates of dispute. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. The functional impairment that the patient was struggling with borderline personality disorder. One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy, which can occur in a less restrictive setting once patients are free from safety concerns, which was the case for this patient. In addition, the Level of Care Utilization System (LOCUS) recommended treatment with high intensity community based services. The patients functional status was moderate due to significant inability to fulfill responsibilities and obligations and her treatment and recovery history were moderate due to minimal treatment response in the past. However, the patient had a lack of current suicidal ideation, was cooperative and demonstrated insight into her need for treatment, and had a stable recovery environment. All told, the inpatient mental health treatment services provided from the dates of dispute were not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for prednisolone sodium phosphate oral dissolving tablets (Orapred-ODT). It is critical for this for this patients family and caregivers to have immediate access to emergency medications, such as epinephrine autoinjectors in case of allergic reactions that occur outside the presence of medical supervision. In addition, adjunctive medications such as systemic steroids and antihistamines, can also be helpful to alleviate the patients symptoms. Although systemic steroids should not be used for initial therapy, there is support for their use as an adjunctive therapy per the American Academy of Allergy, Asthma and Immunology (AAAAI) and American College of Allergy, Asthma and Immunology (ACAAI) practice parameters. Based on the current medical literature and guidelines, there is a lack of data that the Orapred-ODT formulation is more effective than the Health Plans formulary alternative. However, in this case, the patient is school-aged and requires a formulation that will be tolerated and readily available. The Orapred-ODT oral dissolving tablets allow the medication to be separated out into discrete doses to provide access to the medication at multiple locations where the patient could potentially experience an allergic reaction. The availability of medication is important as anaphylaxis requires timely administration of medication. Given these specific circumstances, the requested Orapred-ODT is medically necessary for treatment of this patients medical condition. 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 allergy and immunology with subspecialty certification in pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.