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

A 37-year-old female enrollee has requested a referral to a vascular surgeon for vascular surgery for treatment of the enrollees leg pain. Findings:  The physician reviewer found that sclerotherapy for the treatment of spider veins is not medically necessary. It is possible to have some symptoms in the area of spider veins, but it is generally accepted that spider veins are not the underlying cause of the pain. Although this patient has leg pain, there is no evidence in the submitted medical records of larger varicosities that would be amenable to surgical intervention. As such, the requested referral for vascular surgery is not necessary from a medical standpoint. Furthermore, the request for vascular surgery is not reconstructive in nature as this patients condition does not represent an abnormal structure of the body. Millions of individuals are affected by spider veins, and while they can be unsightly, they do not rise to the level that they are considered an abnormal structure of the body. All told, a referral to a vascular surgeon for vascular surgery is not reconstructive in nature and is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy for treatment of the enrollees sudden idiopathic sensorineural hearing loss. Three physician reviewers found the submitted documentation fails to demonstrate the superior effectiveness of the requested services in this patients case. Multiple articles suggest some modest improvement in hearing with the use of hyperbaric oxygen therapy. Most of these articles state that the effect is greater in patients with a modest degree of hearing loss when the therapy is administered early in the treatment protocol after the traditional use of oral and intratympanic steroids. Bennett and colleagues noted that for people with acute sudden sensorineural hearing loss, the application of hyperbaric oxygen therapy significantly improved hearing, but the clinical significance remains unclear. There is the risk of serious side effects with hyperbaric oxygen therapy. Per the medical evidence, potential risks include damage to ears, sinuses, and lungs from pressure changes, claustrophobia, and oxygen poisoning. At this time, the medical evidence has not established that hyperbaric oxygen therapy is likely to be of greater benefit than other available treatment options. Final Result: 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 otolaryngology 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 otolaryngology 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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a mobility chair (powered wheelchair) for the treatment of his medical condition.  Findings:  The physician reviewer found that the requested equipment has not been established as medically necessary for treatment of the patients medical condition. Finlayson and colleagues reported on the prevalence of multiple mobility device use among adults with multiple sclerosis and examined the association between falls status (faller/non-faller) and the number of mobility devices used. The authors found an association between use of multiple mobility devices and falling. Although a power mobility chair can benefit specific individuals, in this case there is a lack of clinical evidence supporting its use. All told, the request for a mobility chair (powered wheelchair) is not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested equipment 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 with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive language impairment with decreased acquisition of language skills. For these reasons, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) from Hoag Neurobehavioral Health, LLC for treatment of his behavioral health condition.  Findings: The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The records did not show that the patient was in withdrawals. There was no evidence of suicidality, homicidality, violence or aggression towards others. There was no evidence of significant post acute withdrawal symptoms.  He was not a danger to self or others.  He was medically and psychiatrically stable.  He was on Naltrexone. He was not psychotic or manic. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant continued residential services. He was motivated and appeared to be working the program. He demonstrated insight and motivation.  There were no new problems that had arisen. There was no evidence to indicate that returning him to his environment would have led to destabilization.  Although he continued to struggle with his emotions and required further treatment to develop and solidify coping skills, this did not require the structured environment of a residential setting.  He could have received treatment at an ambulatory level of care.  For these reasons, RTC from Hoag Neurobehavioral Health, LLC were not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested  for a repeat, postoperative PET scan.   Findings:  Two physician reviewers found that PET scans are useful to differentiate postoperative changes from recurrent/residual cancer in patients with a history of non-small cell carcinoma. The postoperative CTA of the chest did show a 2.4cm rounded density near the anastomosis. This rounded density may be postoperative in nature, although residual tumor is not excluded.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zohydro ER. The provider recommended continuation of long-term opiate therapy for this patient but there is a lack of support for use of Zohyrdo ER in lieu of standard formulary alternatives. The patient underwent pharmacogenetic testing and there are several extended release alternatives noted as potential treatment options that are on the Health Plans formulary. The use of chronic opiate therapy for non-malignant pain is not recommended by the current clinical practice guidelines. The patient can be treated with a medication that is available on the Health Plans formulary. Thus, the requested Zohydro ER is not medically necessary for treatment of this patients medical condition. One reviewer found that the requested Zohydro ER is medically necessary for treatment of this patients medical condition.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Society of Addiction Medicine (ASAM) criteria can be applied to this patients presentation to determine the appropriate level of care. Based on the records provided for review, the patient does not meet the criteria for treatment at the RTC level of care. Dimension 1 requires documentation of acute intoxication and/or withdrawal potential. Dimension 2 required evidence of biomedical condition and complications. According to the ASAM 3.5 criteria, all six dimensions must be met for placement in this level of care. These two criteria are not met according to the patients presentation. Consequently, the patients presentation does not meet the required six out of six ASAM dimension criteria. Therefore, the RTC services were not and are not medically necessary for treatment of this patient. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia/monitored anesthesia care for a colonoscopy performed for treatment of the enrollee, who underwent a colonoscopy. Findings:  The physician reviewer found that per the medical evidence, during endoscopic procedures such as colonoscopy, monitored anesthesia care is warranted in prolonged or painful procedures such as polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature.  According to current guidelines, during colonoscopy, consciousness during the procedure is acceptable and is the goal during most procedures. For these reasons, the provided records do not support the medical necessity of monitored anesthesia care performed. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology  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 59-year-old male enrollee requested authorization and coverage of Zoladex injections. The Health Plan denied the request indicating that the requested medication is considered investigational for treatment of the enrollees aggressive angiomyxoma.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One CHDR physician reviewer concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female has requested coverage for past circumferential body lipectomy provided for treatment of her excess skin status post bariatric surgery.   Findings:  The physician reviewer found that cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Reconstructive surgery generally is performed to improve function, but may also be done to approximate a normal appearance. Based on the medical documentation available, there is insufficient evidence to support that the procedure was reconstructive in nature. A functional deficit was not adequately defined in the documentation. Further, examination detail with respect to the degree or severity of excess abdominal tissue is lacking.  The American Society of Plastic Surgeons (ASPS) indicate that with respect to treatment following massive weight loss, [w]hen surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. As noted by Manahan and Shermak, common functional problems associated with an overhanging pannus or skin redundancy are described to cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus.    There is inadequate documentation with respect to the degree of abnormality of this patients medical condition. However, the patient was diagnosed with abdominal lipodystrophy, which can be considered an abnormal collection of soft tissue. Obesity can be considered a disease. Obesity correction can create significant functional deficits, but is not documented for this patient. There is minimal supporting medical evidence that a functional deficit is present as adequate detail was not provided to show the degree of abnormality. The examination documentation is insufficient. Without adequate detail regarding the degree or severity of the patients condition, there is insufficient medical documentation to demonstrate that the procedure at issue was reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, or in the alternative, 30 hours per week of direct ABA therapy. Findings:  The physician reviewer found that that ABA therapy is effective for children with autism. ABA therapy is designed to treat the medical problems related to autism spectrum disorder. Studies have found that school age children benefit from ABA therapy when targeting maladaptive behaviors such as non-compliance. Other studies reported a significant correlation between treatment intensity and goals mastered. This patient was progressing and mastering targets slowly, but consistently. He had a considerable decrease in maladaptive behaviors. However, with the decrease in intensity of the ABA services, he demonstrated an increase in maladaptive behaviors. This indicates that he cannot tolerate the change in the hours of ABA services provided. Thus, 30 hours of direct ABA per week is medically necessary to treat this patients autism spectrum disorder and trisomy 21.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 4-year-old male enrollee has requested applied behavioral analysis and ABA supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with applied behavioral analysis (ABA) therapy in children. ABA therapy has been documented, in multiple studies, to significantly improve motor, verbal, and social interactive skills in autistic children. In this case, the patient is a 4-year-old male diagnosed as autistic by age 2 with his assessments indicating significant cognitive delay. The documentation submitted for review also indicates that the patient has made definitive improvement in multiple maladaptive behaviors in an 8-month interval while receiving 33 hours of individual ABA therapy per week. Based on the patients rate of improvement and current level of functioning, 30 hours of ABA therapy per week is medically appropriate and necessary. The patients initial intervention was at a very favorable young age. The patient showed a moderate degree of improvement while receiving 33 hours of ABA therapy per week. He is now nearly 8 months older and the medical literature supports a reduction of ABA hours to be replaced by school attendance and group social activities as the patient ages. As to the supervision, 2 hours per month is medically appropriate and necessary in this clinical setting as his parents have been receiving parental guidance and this intervention can be tapered down to 2 hours per month. As such, a portion of the requested therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 73-year-old male with a history of neck pain. A cervical spine x-ray revealed small posterior spurs at C4-5 and C5-6 but was otherwise normal. The patient has requested authorization and coverage for a CT scan of the cervical spine. The Health Plan has denied this request on the basis that the patient does not meet medical necessity criteria for authorization of a CT scan.  Upon review of the submitted clinical information there is no clear medical indication for a CT scan of the neck. The patient requested a CT scan to identify the source of his neck pain. A CT scan is very unlikely to yield any information that will be useful in the management of the patients condition. Standard of care in this setting calls for a trial of physical therapy before embarking on a diagnostic imaging protocol. Therefore, I have determined the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.