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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for procedure described by the treating provider, surgical resection of the femoral nerve tumor, with nerve stimulation and electromyography (EMG) for further evaluation of functional services related to the pelvic tumor in a joint surgery. The submitted documentation supports the requested services in this patients case. The tumor is causing pain and may ultimately result in a severe neurological deficit as it continues to increase in size. These tumors are more safely excised when they are smaller, and continued delay will increase the risks involved with this surgery. These tumors should generally be removed when they are discovered, as some of these tumors will become malignant over time. Therefore, the procedure described by the treating provider, surgical resection of the femoral nerve tumor, with nerve stimulation and electromyography (EMG) for further evaluation of functional services related to the pelvic tumor in a joint surgery is medically necessary for the 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 neurological 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 15-year-old male enrollee has requested intensive weekly individual mental health therapy for treatment of the enrollees depression.  Findings:  The physician reviewer found that modern psychiatric practice in this country is focused on the aggressive treatment of depression, particularly in the acute phase of the illness, followed by less frequent services, as well as community involvement in the maintenance phase, to foster patient autonomy and recovery. As psychotherapy is the cornerstone of treatment for affective disorders and oppositional behavior, weekly sessions are oftentimes clinically appropriate. Current medical evidence suggests that a short-term increase in services can be effective at improving functionality. The American Academy of Child and Adolescent Psychiatry reports no correlation between duration of treatment and response, suggesting that brief treatments may be an efficacious and economical way to treat depressed youths. Psychotherapies such as cognitive behavioral therapy and family therapy are proven interventions in the treatment of mood disorders in young patients and are well supported by the peer-reviewed evidence-based medical literature. The application of such therapies at a frequency of once a week in this patients case is therefore supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee requested genetic testing to determine the sub-type of ectodermal dysplasia of the enrollees ectodermal dysplasia and type 1 diabetes mellitus to facilitate medical treatment.   Findings:  The physician reviewer found that genetic testing as requested is medically necessary and appropriate for this patient.  Ectodermal dysplasias are a large group of disorders characterized by congenital abnormalities in the ectodermal structures and their appendages, such as hair, teeth, nails, and sweat glands. There are over 150 current syndromes that fall into this classification. Patients with different subtypes require different interventions. Some patients may require extensive dental work and orthodontia to correct associated defects. Genetic testing is currently available for a number of the syndromes, including when a patient presents with mild or atypical ectodermal dysplasias such that a diagnosis cannot be made by clinical findings alone (Bale and Mitchell). The authors noted that testing of the genes to determine underlying cause and infer inheritance pattern will provide the information necessary to offer unaffected, but at-risk, family members testing to determine carrier status. All told, the requested genetic testing will provide critical information to guide this patients treatment. Based on the current state of the literature and related standards of care, the recommended genetic testing is medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested for hepatitis C treatment without having to complete a six-month chemical dependency rehabilitation program for treatment of the enrollees chronic hepatitis C until she has successfully completed a six-month chemical dependency rehabilitation program. Findings:  The physician reviewer found that according to the standard of care in this setting, drugs and alcohol must not be used while a patient is receiving HCV treatment. Whether or not a patient completely or partially abstains from alcohol and illicit drug use prior to the initiation of HCV treatment is only relevant to a patients risk of relapse.this patient should be evaluated at a CDRP to determine whether she requires chemical dependency treatment in order to avoid the risk of relapse during HCV treatment, and if so, what length of chemical dependency treatment is indicated. In the absence of this evaluation, the medical necessity of HCV treatment is not established.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee requested residential treatment for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the record does not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, family counseling, school-based services or evidence-based psychotherapies and pharmacological strategies targeting her addictive illness and psychiatric conditions during the episode of illness.  Further, there is a lack of treatment plans or daily progress notes submitted to support the medical indication for the residential treatment setting.  All told, residential treatment center services were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 10-year-old male with Tourettes syndrome, obsessive-compulsive disorder, anxiety, outbursts (likely related to Tourettes), dizziness, and sleep disorders. He has been treated with Prozac for his obsessive-compulsive disorder. The patient has difficulty following verbal commands in school. The patients intelligence quotient is 92, which is low normal. The patients physicians have recommended neuropsychological testing to evaluate the patient for a possible learning disability. The Health Plan indicates the requested services are not medically necessary for treatment of the patients condition.Upon review of the submitted evidence, it has not been demonstrated that the requested services are medically necessary. The alternatives offered by the Health Plan are medically reasonable and appropriate. The patient should be evaluated by a neurologist for evaluation and treatment of Tourettes syndrome. In addition, the patient should be examined by a psychiatrist for evaluation and treatment of possible obsessive-compulsive disorder. Furthermore, it appears that the school system can provide appropriate testing for purposes of optimizing educational intervention. Therefore, 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: Experimental/Investigational
Decision: Upheld

A 28-year-old male enrollee has requested a standing frame device for treatment of his paraplegia. Findings:  Two physician reviewers found that a standing frame was prescribed to promote skin integrity, build cardiovascular endurance, reduce lower extremity edema, increase range of motion and improve weight-bearing to prevent osteoporosis. The current medical evidence has not established that the requested equipment is likely to be of greater benefit than other treatment options in this patients case. A review of medical literature shows a lack of quality studies that demonstrate the benefits of supported standing with a standing frame.  Specifically, the scientific data does not support that standing frame use decreases contracture, spasticity or osteoporosis. Further, passive standing has also not been demonstrated to offer adequate cardiovascular benefits. Moreover, there are inadequate well-researched studies supporting the benefits of the device for respiratory, urinary and bowel function. At this time, there is insufficient evidence to support its use in this clinical situation.  Therefore, the requested standing frame device is not likely to be more beneficial than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy. Per current peer-reviewed medical literature, the role of proton beam radiotherapy for management of clinically localized prostate cancer remains undetermined. There is a lack of high quality clinical outcomes reported to allow definitive conclusions regarding its safety and efficacy as compared to the standard of care radiation modality, which is photon radiotherapy. Further, a nationally recognized organization does not support proton beam radiotherapy in this patients setting outside the context of a clinical trial. Some reports suggest that proton beam radiotherapy may lead to excessive gastrointestinal and rectal toxicity as compared to photon radiation. One study evaluated 1368 patients treated with intensity modulated radiation therapy (IMRT) or proton beam radiotherapy and found that IMRT patients had a lower rate of gastrointestinal morbidity. The study reported that there were no significant differences in rates of other morbidities or additional therapies between IMRT and proton therapy. Therefore, proton beam radiation therapy was not and is not medically necessary for treatment of this patients prostate cancer. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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

A 62-year-old male enrollee has requested a positron emission tomography (PET) scan for evaluation of his prostate cancer. Findings:  Two physician reviewers found that based on the current peer-reviewed medical literature, conventional CT scans, bone scans, and serial PSA testing are the standard of care to follow a patients progression or resolution of metastatic prostate cancer. There is a paucity of scientific data demonstrating improved health outcomes with PET scanning at this stage in this patients treatment given the findings on CT. Thus, the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard alternative.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested community based adult services (two additional days per week) for medical treatment of her stage IV chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, depression and kidney dysfunction.  Findings:  The physician reviewer found that this patient has a diagnosis of depression and requires assistance with multiple activities of daily living to include meal preparation, toileting, bathing, hygiene, dressing, transfer, respiration, ambulation, and medication management. The patient is also dependent with accessing resources and transportation. However, it is also noted that the patient maintains the assistance of a caregiver, although the documentation provided does not specify the availability of the caregiver. There is also no indication that this patient is unable to attend other community activity centers with or without the assistance of the caregiver for the remaining two days per week. Therefore, the medical necessity for an additional two days per week in the community based adult services program has not been established.
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 Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the diagnostic procedure at issue was 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for occupational therapy at the frequency of four times per week for treatment of her autism spectrum disorder, optic nerve coloboma and myopia. Findings:  The physician reviewer found that the request for occupational therapy at the frequency of four times per week has been established as medically necessary for treatment of the patients medical condition. While the evidence for sensory based OT is emerging, recent studies suggest clinical benefit. Researchers systematically reviewed 27 studies to identify, evaluate, and synthesize the effectiveness of sensory integration intervention on the ability of children with difficulty processing and integrating sensory information to engage in desired occupations and to apply these findings to OT practice. The authors concluded that using sensory integration may provide beneficial outcomes when addressing sensorimotor skills, motor planning, socialization, attention, and behavioral regulation and reading-related skills. In this case, the patient has a complicated medical picture which includes autism spectrum disorder, optic nerve coloboma, myopia, astigmatism for which she wears glasses and hearing loss for which she utilizes bilateral hearing aids. Each of these conditions contribute to significant sensorimotor deficits, making the activities of daily living such as self-feeding increasingly difficult. This fact, coupled with an increasingly restricted diet due to the aforementioned sensory deficits in the context of multiple food allergies that include nuts, wheat/gluten, dairy, coconut, apples, red dye Number 40, and citrus fruits necessitates increased OT services on a weekly basis. Therefore, OT at the frequency of four times per week is medically necessary to ensure increasing levels of independence in the patients activities of daily living, improved transitions and diversified dietary options.  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 sub-specialty certification in developmental-behavioral 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for reconstructive abdominoplasty for treatment of the enrollees diastasis recti. Findings:  The physician reviewer found that this patient presents with an abdominal bulge, abdominal pain, weakness and back pain attributed to a documented large diastasis recti of the abdomen. Work-up of other potential causes of her abdominal condition have not been able to identify a cause other than the diastasis recti. This has included multiple CT scans and plain radiographs. In addition, her condition has appeared to have worsened as the most recent CT evaluation noted the presence of the transverse colon within her protuberance. The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty. As stated by the American Society of Plastic Surgeons (ASPS), abdominoplasty and panniculectomy are typically performed for purely cosmetic indications. However, the ASPS noted that there are however rare reconstructive indications for panniculectomy in cases unrelated to obesity or massive weight loss. This patient has evidence of back and abdominal pain with abdominal weakness. However, given that the repair of diastasis recti is not well-recognized as a reconstructive procedure, repair of the diastasis recti should not be considered medically necessary based on a functional treatment. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. However, the requested surgery is supported as reconstructive in nature. The patient has evidence of significant diastasis recti that can be considered an abnormal separation of the rectus muscles. In addition, the abnormal structure of the body is caused by pregnancy and age. Moreover, the requested surgery is being requested to improve the patients appearance and based on the photographs provided and the current medical literature, the patients preoperative appearance is severe. Thus, this is considered a significantly abnormal appearance. Finally, the requested surgery could offer more than a minimal improvement as the patients current condition is severely abnormal and the planned procedure would directly address abnormality. Thus, the requested reconstructive abdominoplasty is supported as reconstructive in nature, and therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxandrolone 10 mg tablets.The submitted documentation does not support that the requested medication is medically necessary. Polsky and colleagues note that patients should be treated for HIV-associated wasting only if they meet the criteria for wasting syndrome. They also note that there are several other steps that should be taken that would include management of depression, control of viral load, and treatment of diarrhea and any infectious process. In this case, the submitted documentation does not include documentation of any basis for finding that the patient has wasting syndrome. Furthermore, progress notes reflect that the patient has not lost weight, that his weight has been steady, and that he has a BMI in the normal to overweight range. Under these circumstances, oxandrolone 10 mg tablets are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious 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: Upheld

The patient is a 36-year-old female with intractable headaches and spasm of the neck and shoulders. She has requested authorization and coverage for Botox injections. The submitted documentation suggests the patient has failed Maxalt and Cox-2 inhibitors. There is no clear documentation regarding the patients current symptoms or degree of disability. The Health Plan has determined Botox is not medically necessary for treatment of the patients medical condition.The submitted medical records do not demonstrate the basis for the patients underlying disease process. It appears the patient has not undergone usual and customary treatment with physical therapy or tricyclic anti-depressants for chronic neck and head pain. The patients MRI reveals a disc herniation and possible cervical nerve root compression, which may be the primary inciting cause of this patients pain. There is minimal data concerning Botox treatment of cervical pain with or without headaches. The patient has multiple diagnostic issues, which do not appear to have been addressed. For example, the patient is being treated for migraine with Maxalt. If migraine is a component of this patients headache problem, there are many recognized medications that may be tried. The patient has not exhausted available therapies and requires further work-up. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.