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

The patient is a 10-year-old male with issues of social integration, anger outburst and poor sensory processing and modulation. He has had multiple diagnoses from different providers including Aspergers syndrome, anxiety disorder, obsessive-compulsive disorder, and oppositional behavior. He has been seen by a speech therapist who documented that the patients classroom teacher had to give direction directly to the patient on most occasions. The therapist noted the teacher would have to say the patients name, increase the volume of her voice, and gaze at him to get a response; the therapist also noted the patient had difficulties using the restroom because of an inability to snap and unsnap his pants. The therapists evaluation of 1/27/05 noted the patient was unable to tie his shoelaces, had poor organizational skills, and had difficulties in processing modulating sensory input. The Health Plan has denied reimbursement for previous occupational therapy the patient received as well as authorization for additional occupational therapy on the basis occupational therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be overturned. It appears the processing problems described by the patients parents can be associated with Aspergers syndrome and attention deficit disorder. Sensory integration issues are also described in obsessive-compulsive disorder, but are more descriptive in nature. The patients symptoms fall on a spectrum of behavioral disorders. Additionally, the description of the patients behavior and social deficits appears to constitute sensory emotional disturbances. As such, occupational therapy including a sensory integration component is a reasonable treatment approach for this patient and should be continued. The occupational therapy should define specific goals that can be objectively quantified and these goals should be reviewed by the patients psychiatrist or primary care physician every six months. If the goals are not being met, therapy should be discontinued.Based upon the information set forth above, I have determined that the therapy at issue is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female who has been diagnosed with bipolar disorder and has manifestations of a pervasive developmental disability with mild mental retardation. She did well with her symptoms of attention deficit hyperactivity disorder (ADHD) when she was on Ritalin, but the long acting stimulants have caused her to have some agitation. The patient was started on Abilify and Provigil for symptoms of ADHD, depression and other behavioral issues. She was sedated with the Abilify alone, but with the combination of Abilify and Provigil the patient was reported to have done well. The patients parent has requested authorization for continued treatment with Provigil. The Health Plan denied the request citing a lack of medical necessity. A review of the patients history indicates she has had a positive response to a stimulant medication in the past. Initially Ritalin was used and was found to be effective. Over a long period of time it became less effective and was eventually discontinued. The use of Provigil with Abilify has also proven to be clinically effective. Provigil is currently approved by the FDA for the treatment of sleep apnea and other indications not related to ADHD or sedation secondary to third generation antipsychotic medications. Specifically, the use of Provigil to reverse the sedative effects of antipsychotic medications is not an FDA approved application. It is likely that Ritalin would again be effective to reverse the sedation effects of Abilify, and there is no record of a recent trial of this medication. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a male enrollee requested authorization and coverage of continued residential treatment for behavioral disorders.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a MyoPro 2 Motion G orthotic device. Simon and colleagues explain that standard care following brachial plexus trauma includes occupational therapy for functional restoration, including compensatory techniques and measures to mitigate risk of further injury, in conjunction with close monitoring for evidence of reinnervation, which dictates whether surgical interventions may be indicated. Noland and colleagues report that surgical interventions include neurolysis, nerve grafts, and nerve transfers, ideally beginning within six months of injury, and the use of tendon transfers and functioning free muscle transfers. Multiple surgeries may be needed to effectuate a good outcome. However, Shanina and colleagues note that controlled trials are still needed to confirm and optimize surgical therapeutic strategies. Overall, brachial plexus injuries remain frequently associated with poor functional outcomes. Despite these suboptimal outcomes, there is no established role of myoelectric upper limb orthoses in this clinical setting. Pundik and colleauges report that while use of MyoPro in motor learning-based therapy resulted in clinically significant gains with a relatively short duration of in-person treatment, further studies are warranted. Limitations of the study included small sample size, no blinding, and no comparison group. Current medical literature related to myoelectric upper limb orthoses remains preliminary, particularly with respect to long-term outcomes data such as safety and adverse sequelae, and there is a lack of data  proving clinically significant health or functional benefits. Currently available myoelectric upper limb orthoses are bulky devices that can potentially cause or exacerbate edema, skin injuries, musculoskeletal injuries, neural traction and pain. Given that further well-designed studies of an unbiased nature are required to better understand the adoption of these types of devices in clinically meaningful settings, to determine whether function is improved, and to establish long-term safety, the requested device is not medically indicated. Therefore, a MyoPro 2 Motion G orthotic device is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 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: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression.   Findings:  Three physician reviewers found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer reviewed studies, Schutter and colleagues reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for MDD. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, the TMS therapy provided this patient from the date in question and forward will likely be more beneficial for treatment of the patients depression than any available treatment modality.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested physical therapy and occupational therapy on an in-home basis for the treatment of the enrollees global developmental delay and hypotonia.  Findings:  The physician reviewer found that Carboni and colleagues report a fairly good outcome in hypotonic children, but state that muscle stretching by physical therapists is essential for these children to evolve improved motor function. Parush and colleagues have a less favorable outlook for these children and suggest that hypotonia will continue to plague their large motor groups throughout childhood when compared with their peers. The authors recommend continuous physical therapy and occupational therapy. Other forms of congenital hypotonia are due to primary myopathies which have a variable prognosis depending on the form of myopathy. Even in an example of a relatively severe myopathy, physical therapy is recommended even when the patient is extremely hypotonic (Malicdan and Nishino). Given this literature support, physical therapy and occupational therapy are medically necessary for this patient. However, there is inadequate justification for in-home services. All told, physical therapy and occupational therapy at the Health Plans facility is medically necessary to address this patients medical condition. Therefore, a portion of the requested therapy is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 10-year-old male who has been diagnosed with autism spectrum disorder and attention deficit hyperactivity disorder. Findings:  The physician reviewer found that the time of evaluation  his speech was 80% intelligible in unstructured settings. He was using four to five word phrases 50% of the time with minimal prompting, and answering wh questions 50% of the time. According to a speech and language pathology noted, he has been receiving speech therapy for 60 minutes once per week.  His mother notes that he was non-verbal until three years ago. The reports show that the patient has been making progress with speech therapy. His intelligibility increased to 85% intelligible to familiar and unfamiliar listeners , with a significant decrease in jargon and gibberish, and increased frequency of independently facing his listener. The raspy quality of his speech had decreased. He was using three to five word phrases in structured and semi-structured tasks in 70% of opportunities, and answering wh questions had increased to 80% of the time with minimal prompts. He had difficulty with pragmatic language, with breakdown of communication with over five exchanges of non-preferred topics.Speech therapy is a crucial intervention for children with autism spectrum disorder. Children with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words (Paul). Treatment of patients with autism spectrum disorder involves intensive behavioral therapy and educational programming, along with traditional ancillary services, such as speech and language, occupational, and physical therapies. In addition, older children with autism spectrum disorder require speech therapy that addresses pragmatic language. The substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. This patient has autism spectrum disorder, and has only been verbal for the past three years. Although his expressive and receptive language are still significantly delayed, he is documented as making progress with weekly 60-minute therapy sessions. Given this support, the requested speech therapy services once a week are medically necessary for treatment of the patients medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested Zometa (zoledronic acid) infusions for treatment of her medical condition. Findings:  The physician reviewer found that zoledronic acid is indicated for the reduction of skeletal related events in patients with metastatic solid tumors and multiple myeloma. It is also indicated for the treatment of osteoporosis. This patient has two indications for treatment with zoledronic acid. She is at very high risk for osteoporosis, given her early age of menopause, and she is already diagnosed with osteopenia. Zoledronic acid is compendia listed for bone loss from cancer treatment. This patient meets the criteria for this treatment. In addition, a phase III study has shown that zoledronic acid can reduce the risk of disease progression in pre-menopausal women, rendered post-menopausal as a result of treatment. This patient also meets this indication as well.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested cryotherapy for the treatment of her cystic acne. Findings:  The physician reviewer found that this patient has cystic acne that has been resistant to treatment.  She has tried and failed topical retinoids and oral antibiotics, and neither is safe to use in pregnancy. Her pregnant state limits the options for treatment of her acne.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for electromyography (EMG) and nerve conduction study (NCS) (CPT codes 95886 and 95913). The records provided for review demonstrate that this patient has a history of migraine, cervicalgia, dizziness, and paresthesia of skin. She has been treated with topiramate and trazodone, which she was unable to tolerate, per the providers reports. The provider has recommended evaluation with EMG and NCS to determine whether the patient has any evidence of active denervation. Per Li and Tavee, although NCS is an important part of a patients electrodiagnostic examination, the diagnosis of radiculopathy rests mainly on the needle electrode examination findings. This supports the utility of both NCS and EMG in this clinical setting. Performing EMG with NCS will help determine whether the patient requires further radiological imaging or neurosurgical intervention. For these reasons, the requested EMG and NCS (CPT codes 95886 and 95913) are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology 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 41-year-old female enrollee has requested a continuous glucose monitoring system for the treatment of her diabetes. Findings:  Two physician reviewers found that this patient would benefit from a continuous glucose monitoring system.  The system is designed with alarms to protect the patient from high and low glucose levels. Better control of glycemic states would allow more intense control of her condition. Continuous glucose monitoring may provide her with maximal glycemic control without significant and life-threatening complications.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested outpatient mental health treatment for treatment of his behavioral health condition. Findings:  The physician reviewer found that this patient had a trial of Effexor and adjunctive Abilify. The submitted letter from the patients provider relates that he did have successful pharmacotherapy treatment in the past. There is no indication that this patient had other medication trials such as selective serotonin reuptake inhibitors (SSRIs) or tricylics. This patient had depressive symptoms which included psychomotor symptoms yet he was treated with a very intensive form of therapy, requiring good cognitive functioning and motivation. The efficacy of such therapy in this patient population is unclear. Lastly, there is no evidence that other less intensive measures such as CBT have been tried, and for patients such as this, the literature supports the contention that CBT was indicated. Given these facts, the medical necessity of the psychotherapy received, and the medical necessity of future psychotherapy is not supported at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 1-year, 10-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that as noted by Law and colleagues, children with speech delay can be successfully treated, as confirmed in this meta-analysis of multiple medical journal articles. Further, one prospective study from Pennington and colleagues commented on the accuracy of speech testing in a two-year-old population. The authors evaluated patients who were diagnosed with speech delays when they tested below the 10th percentile in expressive language. The authors concluded that these patients were correctly diagnosed, which prompted treatment with speech therapy resulting in marked improvement. There is robust medical literature that supports the medical necessity of the requested speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for myocardial perfusion imaging and transthoracic echocardiogram. The patient has a multi-year history of chest discomfort. She has significant risk factors for coronary artery disease (CAD) including hypertension, hyperlipidemia, and systemic lupus. The records provided for review document that the patients most recent nuclear ischemic evaluation was in 2017. Evaluation has also included two echocardiograms in the past three years. The most recent echocardiogram was in March 2019, and it revealed normal left ventricle (LV) function, as well as no significant valvular heart disease, pulmonary hypertension, or pericardial effusion. Three years have passed since the patients last nuclear study and she remains at increased risk for CAD. Thus, a repeat nuclear ischemic study is indicated. However, in her most recent presentation, she lacked signs and symptoms concerning for LV dysfunction, pulmonary hypertension, valvular heart disease, or pericardial disease. The patients two echocardiogram studies were interpreted as normal. There is no reported intercurrent myocardial infarction, change in electrocardiogram or symptoms, or hypotension. Therefore, a repeat echocardiogram is not appropriate based on clinical presentation and published guidelines. Therefore, the requested myocardial perfusion imaging is medically necessary, while the requested transthoracic echocardiogram is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is 62-year-old female with gastroparesis secondary to diabetes. The addition of Zofran 8mg daily to the patients regimen of Zelnorm has helped improve the patients symptoms. Previous trials of Reglan and domperidone were not as effective as Zofran. Prior to the initiation of Zofran, the patient required a prolonged hospitalization. At issue is whether Zofran is medically necessary for treatment of the patients condition.The use of Zofran in this patient is medically appropriate and indicated. She has documented gastroparesis manifested by nausea and vomiting. Traditional treatment and therapies have not been effective. Although Zofran has not been approved by the Food and Drug Administration for this diagnosis, it has proved to be effective for this patient. As such, it is medically reasonable for the patient to continue on Zofran 8mg daily to relieve her symptomatology and avoid hospitalization. Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested physical therapy for treatment of his spinal stenosis/degenerative spondylolisthesis.   Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity of physical therapy has not been established. In this case, the patient has diabetes with peripheral neuropathy and chronic nerve injury.  He has bilateral lower limb weakness impairing his functional mobility. Treatment to improve his function has included a skilled nursing facility stay, provision of adaptive devices, and outpatient physical therapy. He has a home exercise program and he is able to perform it. Continued skilled physical therapy services are not medically necessary given the intensive instruction he has had to date.  He lacks sufficient strength in his ankle dorsiflexors for it to be a safe to ambulate without AFOs and using a cane. He currently uses a walker and but stopped using the AFOs. The medical literature cited above does not include physical therapy as an efficacious treatment modality for regeneration of peripheral nerves. As such, additional physical therapy to ambulate with a cane is not reasonable or medically necessary. Therefore, the requested physical therapy is not medically necessary for treatment of the patients medical condition.