Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for single photon emission computed tomography (SPECT) scan for evaluation of the enrollees behavioral health conditions. Findings:  Three physician reviewers found that SPECT scanning is a sophisticated nuclear medicine study that examines blood flow in the brain with the assistance of a radioactive tracer that is introduced to the patients body.  Brain activity demands blood flow, so it is postulated that SPECT can provide information regarding hyperactive, suboptimal or normal functionality of specific brain structures and regions.  Advances in neuroimaging techniques, such as SPECT, present an exciting, and potentially useful, expansion of the collective knowledge base.  However, the technology is still in its infancy, and meaningful correlation between clinical presentation and specific brain activity patterns does not yet exist.  Per the records, the patient was prescribed a trio of activating medications including noradrenergic enhancers and a stimulant. This regimen could have contributed to his anxiousness and irritability.  Further, there was no evidence that the patient had failed evidence-based, non-pharmacologic interventions, such as cognitive behavioral therapy, psychodynamic psychotherapy or interpersonal therapy.  Final Result: The 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: 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: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female with migraine headaches. The records from her neurologist dated February 2006 indicate a change in frequency from two headaches per month to four headaches per month.  He prescribed Imitrex nasal spray and injectable Imitrex. There are no additional notes regarding a previous failure of oral triptans or her response to this treatment plan. It is unclear if the patient has had any ongoing follow-up with the specialist.  The patient has requested authorization for 10 Imitrex injections per month.  The Health Plan determined the requested quantity of medication is not medically necessary, and denied her request.The records provided for review document that the patient has migraine headaches and that these headaches respond to Imitrex injections. However, the records indicate the migraines occur four times per month, and the evidence does not support the need for 10 Imitrex injections per month. Therefore, a request for 10 Imitrex injections to treat four migraines per month is not medically necessary.  If the frequency of the patients migraines should increase substantially, preventative therapy and a trial of oral or nasal triptans would be recommended.Based upon the information set forth above, I have determined the requested quantity of medication is not medically necessary for treatment of the patients medical condition. 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 six weeks of residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not indicate that the patient has severe physical health concerns at this time. She does not have substance use issues. The supplied documentation does not indicate suicidal or homicidal ideation. Based on the records, the patient could receive effective treatment on an intensive outpatient basis due to her lack of self-harm behaviors and lack of active suicidal or homicidal ideation. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for the treatment of eating disorders. The literature supports therapy on a consistent basis along with medication for eating disorder treatment. Based on the records, it is not clear that she has failed less restrictive treatment options. The records indicate that the patient can be safely and effectively treated in a less restrictive setting. Therefore, residential treatment center services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

An enrollee has requested authorization and coverage for an implantable electrical bone stimulator for the right ankle.The submitted documentation supports that the requested device is medically necessary. Medical literature support the efficacy of bone growth stimulation as a fracture healing modality in the appropriate clinical situation. In this case, the patient remains symptomatic four and a half months after sustaining a fracture and has pain over the medial malleolus in addition to MRI evidence of the absence of a healing reaction. Use of a bone growth stimulator for the treatment of the ununited fracture of the medial malleolus is reasonable and appropriate in this clinical situation. Accordingly, the requested implantable electrical bone stimulator for the right ankle is medically necessary to treat the medical condition.Final Result: The reviewer determined that the requested device 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: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollee diagnosed with autism. Findings:  The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech/language and social interaction. Deficits in fine and gross motor skills as well as processing of sensory and motor information are also common. There are likely a multitude of etiologies, with clinical symptoms being the final common denominator.  Many approaches have been used to facilitate development of adequate communication and interpersonal skills for children with autism.  Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy.ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for children with autism.  In a study by Eikeseth and colleagues comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning and fewer social problems.  Howard and colleagues reported similar results.  Behavioral approaches are considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy.  Volkmar and Pauls noted that behavioral therapy can effectively be used to foster desired behaviors and systematically decrease problem behaviors.  ABA therapy has been used and studied for decades, and studies show positive results from consistent implementation of this method.  Behavioral therapy is not limited to children in early intervention programs, although this is a group that has been well-studied. The principles and practices of behavioral analysis can be applied to people throughout their lifespan, with duration of therapy based on the clinical presentation and response to therapy. All told, 15 hours per week of ABA therapy from the date in question and forward was and is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 45-year-old female enrollee has requested emergency services for the treatment of her jaw pain. Findings:  The physician reviewer found that this patient is a 45-year-old female who was evaluated in the emergency department with complaints of right-sided lower jaw and tooth pain. Her symptoms had been present for three days. She reported that she had used Vicodin and topical Oragel for pain at home without relief. The patient described her pain as throbbing and rated it a 10 on a scale of 1 to 10. Her past history was significant for a tympanic membrane repair with subsequent recurrent and persistent right facial pain. Physical exam revealed some swelling in her right lower mouth.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous implantation of neurostimulator electrode array epidural (CPT code 63650). Researchers performed a review of the available literature evaluating the efficacy and safety of dorsal root ganglion stimulation for the treatment of various forms of neuropathic pain. The authors reported successful use in treating a wide range of indications including postsurgical pain, CRPS, and phantom pain. The authors also analyzed the effects of dorsal root ganglion stimulation on the treatment of chronic neuropathic pain. The authors found that patients reported that dorsal root ganglion stimulation improved patients pain by 56% at one-year post-implantation. In this case, the patient has tried and failed multiple neuropathic agents, opioid therapy, and lumbar sympathetic blocks without substantial benefit in his pain. He continues to use physical therapy, osteopathic care and Pilates to manage his pain with mild benefits. The provider document that the patient underwent a successful seven-day trial for dorsal root ganglion stimulation for his CRPS with 90% relief of his lower abdomen and groin pain. The patient reported that his pain relief allowed him to tolerate wearing pants for the first time in several years, which represented a significant improvement in his quality of life. The peer-reviewed medical literature has demonstrated the safety and efficacy of dorsal root ganglion stimulation in cases of CRPS. Based on the current medical literature and this patients positive response to the dorsal root ganglion stimulation trial, the requested percutaneous implantation of neurostimulator electrode array epidural (CPT code 63650) is 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 anesthesiology with subspecialty certification in pain management 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 patient has requested authorization and coverage for sleep study. Findings:  The physician reviewer found that the records provided for review document that this patient has mild obstructive sleep apnea (OSA) by home sleep study, which demonstrated an apnea/hypopnea index (AHI) of 14 episodes per hour, which is borderline moderate OSA. Home sleep studies can underestimate the severity of OSA but are useful to rule in OSA without regard for severity. As this patient is symptomatic with excessive daytime sleepiness, positive airway pressure (PAP) therapy is indicated. The American Academy of Sleep Medicine (AASM) state that providers should use PAP, compared to no therapy, to treat OSA in adults with excessive sleepiness. The AASM guidelines recommend in-laboratory titration for effective PAP therapy. Therefore, the requested sleep study (CPT 95811) is 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 internal medicine with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old female enrollee has requested a WalkAide device for treatment of her right-sided hemiparesis and right-sided foot drop. Findings:  Three physician reviewers found that the patient has functional deficits in ambulation related to a foot drop which causes the patient to fall.  She has had multiple falls in the past, and she recently sustained a right humeral fracture after falling. Based upon the submitted documentation, there is a lack of evidence indicating that a functional electrical simulation device would provide any better function as compared to the use of the ankle foot orthosis. Additionally, there is a lack of information that the device at issue would reduce the number of falls as compared to standard therapy.  All told, the superior efficacy of the WalkAide device as compared to available standard treatment modalities has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested air and ground ambulance transport services for medical treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Intracranial hemorrhage can result in various sequelae, including severe functional and cognitive impairments and recovery can take months or longer (Naidech). There is a lack of support in the medical literature that establishes that functional or health outcomes following severe hemorrhagic strokes are significantly improved with family/caregiver proximity or involvement during inpatient rehabilitative care. In this case, the patients transfer to a skilled nursing facility in Ohio versus a similar type facility in California was not medically necessary for treatment of the patients health condition. Therefore, the transfer of the patient from California to Ohio by air and ground ambulance transport services was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

This patient is an eight -year-old male with a diagnosis of autism who has been receiving speech therapy since 2002. A review of the speech therapy records demonstrates progress in expressive language skills; the most recent testing in August 2005 indicates his expressive language skills are within normal limits. The patients pragmatic language skills continue to be delayed. The goals for pragmatic skill development include communication with a partner in asking questions, transitioning topics, sustaining attention on topics and non-verbal communication during a conversation.  They are also working on the rate of speed for speech, \th\ sounds and social speech. The patients mother has requested reimbursement for the speech therapy provided in October 2004.  The Health Plan concluded the therapy at issue is not medically necessary, and denied her request.The clinical records from the speech therapist indicate there are continued deficits in the patients pragmatic speech, but that he is making progress.  I reviewed the literature to determine what standardized testing is available in the area of pragmatic speech and found very little. The Pragmatics Profile of the CELF-4 used in this case appears to be the most accurate test available.  Pragmatic speech delays are a primary delay in children with autism. When working with these delays, treatment success is measured in years not months. The therapist in this case has documented objective evaluations and gains sufficient to conclude the patient has benefited from his previous therapy and is likely to benefit from continued therapy.   Periodic retesting using the Pragmatics Profile, or a newer evaluation tool if available, should occur at six-month intervals to evaluate for continued improvement.Based upon the information set forth above, I have determined 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: Overturned

The mother of a 17-year-old female enrollee requested authorization and coverage of a referral to a plastic surgeon for evaluation for possible breast reduction surgery. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees breast hyperplasia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wheelchair power seat elevation installation and repair for treatment of the enrollee, who has been diagnosed with multiple sclerosis.Findings:  The physician reviewer found that this patient has a history of multiple sclerosis.  The records submitted for review, however, do not include any physical examinations or functional evaluations by a physician, physical therapist, occupational therapist or equivalent objective professional (i.e., not affiliated with the product vendor) documenting the relevant neuromusculoskeletal examination and functional ability findings. These assessments should be included for the proper prescription of durable medical equipment, and to establish the eligibility of this equipment, or accessories thereof. The available records in this case do not objectively establish that the requested power seat elevation device is necessary for independent transfers.  There are no indications that the patient could not independently transfer to a bed, chair, toilet or other surface without the equipment in question, including when using implements such as a sliding board after appropriate training. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with childhood onset gender dysphoria. The patient transitioned socially and was started on hormone suppression. She began estrogen treatment. One provider reports that the patient has demonstrated improved mood and increased happiness with each step of her transition. The patient has experienced ongoing and persistent symptoms of gender dysphoria. The patient is seeking vaginoplasty surgery with the support of her parents. She is stable on current hormonal treatment and there is no evidence of any mental health or medical barriers to the surgery. At issue in this case is whether intersex surgery (vaginoplasty commonly known as MTF bottom surgery) is medically necessary for the treatment of the patients medical condition. Genital surgery is often the last, and the most considered step in the treatment process for gender dysphoria. According to the World Professional Association for Transgender Health (WPATH), relief from gender dysphoria cannot be achieved without modification of the patients primary and secondary sex characteristics to establish greater congruence with their gender identity. In this case, the patient has a diagnosis of gender dysphoria that has persisted through puberty. The patient transitioned from male to female (MTF) several years ago with hormone suppression and estrogen. In addition, multiple evaluations from medical and mental health professionals, as well as letters from her parents and grandparent, state that the patient has successfully transitioned to female in all aspects of her life. Therefore, intersex surgery (vaginoplasty commonly known as MTF bottom surgery) is medically necessary for the 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for FreeStyle Libre 14-day continuous glucose monitoring system (CGMS) (consisting of a handheld reader and a sensor worn on the back of the upper arm). The FreeStyle Libre is a relatively new CGMS designed specifically to assist patients in monitoring their blood glucose levels at home (Fokkert). Studies have shown that FreeStyle Libre use can help patients improve glycemic control, reduce frequency of hypoglycemic events, and increase overall patient satisfaction (Biodonde, et al.). This patient presents with type 2 diabetes. He has experienced hyperglycemia and he reports that he has been unable to monitor his diabetes with finger sticks. The provider noted that the use of the FreeStyle Libre 14-day will continue to help the patient manage his diabetes. For these reasons, the requested FreeStyle Libre 14-day CGMS (consisting of a handheld reader and a sensor worn on the back of the upper arm) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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.