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

The patient is a 16-year-old female who was admitted to a residential treatment facility in September 2006. Her care was authorized through October 2006. Treatment records indicate the patient is not being treated with medications because of her refusal to accept them. The parent states the patient continues to be a danger to herself and others in that she remains aggressive toward others. Prior to admission, the record indicates the patient engaged in high-risk behaviors.The progress notes from the residential treatment facility demonstrate that the patients primary therapy is conducted by a licensed marriage and family therapist (LMFT). Other groups were conducted by bachelor level therapists and trainees. There are some notes written by a psychologist (PsyD) and a licensed vocation nurse (LVN). There is no documentation of a psychiatric evaluation or of weekly progress notes from a psychiatrist. The treatment records strongly suggest a major depressive disorder, but according to the record provided no psychiatric referral or intervention was initiated.The primary focus of the patients treatment appears to be a 12-step program with individual sessions, group sessions and activity therapy. The progress notes prior to October 2006 document that the patient was not a threat to herself or to others, but she did continue to demonstrate signs and symptoms of a depressive disorder. According to the treatment records, there has been only minimal progress in addressing the mental health issues identified in the admission assessment. The facility did recommend that the patient return to the home of her mother but when the mother declined to take the patient home in October 2006, the health plan authorized an additional 10 days for appropriate discharge planning. As of October 2006, when continued authorization of residential care was denied, the primary issue appeared to be a parent-child relationship problem.  The parents request for retrospective reimbursement to October 2006 and on-going authorization for residential treatment services was denied by the Health Plan citing a lack of medical necessity.The patient was authorized for one month of care in the residential treatment facility. Her treatment plan did not include input from a psychiatrist and the facility did not offer pharmacological intervention. The patient apparently improved to the level where discharge was contemplated, but she was not able to return to the home of her mother and appropriate placement needed to be arranged. The health plan authorized 10 additional days of residential care so that the facility could identify an alternative placement for the patient. As of October 2006 the patient was clearly ready for discharge and no longer met criteria for residential treatment services. Based upon the information set forth above, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested Prilosec 40mg for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that pharmacologic therapy for GERD continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis. PPIs continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion, although inter-patient variability of the efficacy has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic end points or side effects profile. In this case, the patient should be a given a trial of Protonix single and double doses for eight week each. If she fails to respond to these trials, then she should be approved for Prilosec. She has already failed Prevacid, Aciphex, and generic omeprazole.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy at a frequency of one hour per week or two sessions per week for 30 minutes per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has a significant speech delay.  There are two important factors regarding his potential for improvement.  He has responded, although slowly, to speech therapy, and all testing has indicated that he is intellectually normal. Patients such as this child are routinely referred by the medical community for speech therapy.  The medical literature strongly supports the medical need for this patient to continue speech therapy.  There is a robust medical literature supporting speech therapy in this population. A study by Law, et al. found that children with speech delay can be readily treated. In addition, a paper by Goorhuis-Brouwer and Kniff stated that cognitively normal children are ideal candidates for successful speech therapy. Further, a study by Emmanuel, et al. concluded that speech therapy has been found to be efficacious in the treatment of speech delays in young children. Therefore, the requested therapy is medically necessary and appropriate and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of child enrollee has requested rizatriptan 5 mg, 30 tablets per month for treatment of the her migraines. Findings:  The physician reviewer found that he submitted documentation supports the requested medication quantity in this clinical setting.  There is no one size fits all for treatment guidelines in the pediatric and adolescent population for migraine and its variants that include cyclic vomiting.  This patients symptoms are affecting her quality of life.  Rizatriptan has been found to be safe and well-tolerated in this age group when taken orally.  Migraine frequency and its disabling associated symptoms can frequently flare, and 30 tablets of rizatriptan per month may be warranted when patients experience an increase in the frequency of migraine headaches. Final Result: The reviewer determined that the requested medication quantity 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 neurology with special qualification in child 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Based on current peer-reviewed medical literature, the first-line recommendations for the treatment of OCD include selective serotonin-reuptake inhibitors (SSRIs) or clomipramine, and cognitive behavioral therapy. A recent meta-analysis found active repetitive TMS to be clinically and statistically superior to sham treatment. Moreover, researchers reported that protocols targeting the supplementary motor area have been found to be helpful for OCD in multiple randomized controlled trials and meta-analyses. This patient has undergone multiple trials of evidence-based treatment for OCD. The provider reports that the patient has been treated with three SSRIs, clomipramine, and four atypical antipsychotics as well as other psychotropic agents. He also reports having had a trial of cognitive behavioral therapy. For these reasons, the requested TMS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested TMS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block for treatment of the enrollee who has a history of migraine headache. Findings:  2/3 of the physician reviewers found that migraine is commonly associated with pain in the neck, and back of the head, in as many as three out of four people. There are many treatment options for people with migraines, including acute medications such as sumatriptan, and a wide variety of preventative medications can also be used. Nerve blocks are widely accepted in the headache treatment community as potentially beneficial. They are used for acute treatment of acute headache, as well as preventively. Studies have generally shown advantage to the use of steroids in combination with anesthetic in the context of cluster headache. Nerve blocks are generally accepted as safe, though as with any procedure, there can be potential complications. Per the records, she has had benefit from prior occipital block.  However, the documentation does not indicate a history of prior medication use, nor the specific purpose for which nerve block was applied.  The documentation does not support that blocks are more beneficial than standard treatment, as there is no indication of what prior treatments have been provided and the results thereof. As such, the medical records do not support that occipital nerve block is likely to be more effective than other methods for the treatment of this the patients migraine headache condition.  Final Result: 2/3 of the reviewers determined that the requested services are 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy compared to two-dimensional imaging alone.  Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology 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: Overturned

This patient is a 55-year-old woman with arthritis involving both knees. She had a series of Hyalgan injections in late 2004 through early 2005, which provided pain relief for almost one year. The patient has tried oral anti-inflammatory medications and corticosteroid injections according to her orthopedist. At this point in time, her pain has returned and she has requested authorization for a repeat series of Hyalgan injections for both the right and left knees. The Health Plan denied this request on the basis that the therapy is not medically necessary for treatment of her arthritis.The patient is relatively young and has severe arthritis in both of her knees. Non-steroidal anti-inflammatory medications and intra-articular injections have not been successful. The first series of Hyalgan injections was performed more than one year ago and resulted in significant pain relief. Although the patient is likely to require knee replacement eventually, for now a second series of Hyalgan injections is an appropriate non-surgical option to alleviate her pain. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested cold therapy device for treatment of his status post shoulder surgery. Findings:  The physician reviewer found that although cryotherapy has long been utilized in orthopedic surgery for pain relief, there has been a wide variation in its use, with a lack of evidence for improved clinical outcomes. The literature is conflicting regarding the value of cryotherapy after surgery (Nyland and Nolan). Evidence of decreased subacromial and glenohumeral temperature is lacking, even when some analgesic effect is noted. No increased effectiveness in reducing intra-articular temperature has been seen in the use of a device as compared to ice (Warren and colleagues).  All told, there is a lack of evidence supporting the medical necessary for the use of a cold therapy device for the treatment of this patient.  The cold therapy device at issue was not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested BRCA genetic testing for evaluation of her risk for developing breast cancer.   Findings:  Three physician reviewers found that BRCA testing is used to detect mutations that are associated with a relatively high risk of breast and/or ovarian cancer within a family constellation. There are a variety of guidelines used to recommend this testing in women without a personal history of breast cancer, including the most reliable, provided by the U.S. Preventive Services Task Force. The USPSTF states that testing may be indicating in patients if they have two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger. There are also further suggestions for testing in patients with ovarian cancer in the family, which does not apply to this patient. Given that this patient is considered to be at low risk and unlikely to have positive results on BRCA testing, the requested diagnostic testing is not likely to offer information valuable in her treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old woman with chronic constipation who has been treated for irritable bowel syndrome with several medications including Elavil, Synthroid, Protonix, and Zelnorm. Zelnorm was initiated in October 2003 with an apparent reduction in the patients symptoms. The patient was continued on Zelnorm for up to 24 weeks of therapy. A request has been made for further treatment with Zelnorm. The Health Plan has denied authorization for the requested medication on the basis that it is not medically indicated for treatment of the patients condition.Zelnorm has been approved by the Food and Drug Administration (FDA) on the basis of clinical trials involving treatment up to 12 weeks. Although the drug has limited efficacy and has not been shown to be superior to conventional treatment it is superior to placebo and has had some use in the gastroenterology community. Furthermore, it has only been studied for use over longer periods in an open label study (see citation above). In that study, almost 50% of patients dropped out and there was a 4.4% incidence of serious adverse effects. The patient has received twice the duration of Zelnorm treatment approved by the FDA. To date, there is no evidence that the drug is efficacious over a longer period of time. Furthermore the safety of long-term use of Zelnorm has not been documented in extensive peer-reviewed clinical trials. As such, further treatment with Zelnorm is not medically indicated at this time.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of ovarian cyst. Findings:  The physician reviewer found that the cyst is decreasing in size, as is expected for a benign process. Ovarian cysts are common, and most resolve with time. This patient describes pain and other symptoms that are unlikely to be related to the ovarian cyst, particularly since the cyst has decreased in size. The providers noted that the cyst is not likely the cause of the patients symptoms and surgery is not indicated. In addition, she has risk factors for surgery, including obesity and two prior abdominal procedures. One provider indicated the patients symptoms are likely urologic in origin, though she also may have gastrointestinal issues that could be contributing to her pain. She has not had an evaluation for non-gynecologic causes of her pain and symptoms. There can be many other causes of abdominal and pelvic pain, most of which do not require surgical intervention, and these have not been assessed. There is no indication from the patients work-up that her symptoms would resolve with removal of the ovarian cyst. All told, the requested removal of ovarian cyst is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 obstetrics and gynecology 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: An enrollee has requested reimbursement for platelet-rich plasma services for treatment of the enrollees knee pain. Findings:  2/3 of the physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the services at issue.  There is an absence of large well-designed clinical studies to support the safety and efficacy of platelet-rich plasma in knee meniscal and cartilage disorders. This patient was treated with platelet-rich plasma for his left knee complaints, diagnosed as left medial meniscus pathology. There was no compelling rationale to support platelet-rich plasma treatment for this patients left knee pain over other conservative nonoperative treatment options. Therefore, platelet-rich plasma services provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.