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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested applied behavioral analysis (ABA) therapy utilizing the Lovaas technique for treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine and gross motor skills and processing of sensory and motor information are also common.  ABA therapy is a behavioral approach with a longstanding history of application with children on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism. Behavioral approaches are considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy. The medical literature reported a systematic review of empirical studies of treatment programs for children with autism. The authors found that only interventions based on applied behavior analysis (ABA), specifically those based on the Lovaas model, met predetermined, published criteria for being well-established treatments. Based on the support in the medical literature, ABA therapy utilizing the Lovaas technique is medically necessary for this patient.Final Result: Three reviewers 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: Reviewer 1 is board certified in pediatrics and pediatric critical care and is actively practicing. Reviewer 2 is board certified in neurology with sub-specialty certification in child neurology and is actively practicing.  Reviewer 3 is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

The patients parent has requested authorization and coverage for group speech therapy for an hour, once a week and after school hours. Researchers recommend that 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. The authors noted that further development of therapy plans and interventions targeting pragmatics is lacking. At present, per the description by the patients speech provider of his behavior, the requested group speech therapy is not medically necessary. While he should benefit from continued individual speech therapy, his behavior is not conducive to him benefitting from group speech therapy. The patients behavior is also likely to be disruptive to other children in the group speech therapy session. The provider reports that the patient has limited joint attention and his inability to be present prevent him from participating and being successful in a social learning group. The patient has also demonstrated grabbing behaviors that interfered with the therapy process. For these reasons, the requested group speech therapy for an hour, once a week and after school hours, is not medically necessary for 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Botox (Botulinum Toxin) injections. Findings: At issue is whether Botox (Botulinum Toxin) injections are medically necessary for the treatment of this patient. The current medical evidence supports the requested medication in this clinical setting. An increased number of clinicians have adopted the use of Botox in the management of temporomandibular disorders (TMD) as either a standalone treatment or as an adjunct. A study conducted a systematic review of the relevant literature and concluded that a number of studies have shown promising results that support the use of botulinum toxin in the management of TMD. Another study has also concluded that Botox injections have shown to be safe and effective for treatment for myofascial temporomandibular joint disorder. In this case, the patient is noted to suffer from chronic pain and heavy cramping in her jaw muscles. Records indicate that she has failed NSAIDs, physical therapy and treatment with a bite guard. The patient has previously tried Botox, with significant improvement. As noted above, Botox has been found to be of benefit for the treatment of pain in temporomandibular joint (TMJ) dysfunction patients. Under these circumstances, the requested Botox (Botulinum Toxin) injections are medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for this patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology, with subspecialty certification in neurotology, 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 seven-year-old male enrollee has requested one hour of speech therapy twice per week for treatment of the enrollees autism. Findings: The physician reviewer found that regarding the request for speech therapy services for one hour, two times per week for the treatment of this patient with autism, the services are supported as medically necessary based on overall evaluation of the peer reviewed medical literature (Myers, et al). Key to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal development of language or motor behaviors that are seen in children with autistic spectrum disorder. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to speech delay. Given this patients deficits as described in the recent speech evaluation, the request for one hour of speech therapy twice per week is clinically indicated and therefore medically necessary for management of his condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested an oral appliance for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation failed to demonstrate the medical necessity of the device.  Sutherland and colleagues noted that oral repositioning devices may be an alternative to continuous positive airway pressure (CPAP) in patients with mild to moderate sleep apnea, defined as over five episodes of upper airway obstruction per hour (AHI greater than 5) with daytime symptoms such as sleepiness, cognitive impairment, and effects on quality of life.  Per the clinical notes, this patient presented with AHI of 4.3 in an overnight sleep study.  Additionally, the report documented that the patient had no complaints of symptoms such as daytime sleepiness.  Therefore, there is a lack of support for an oral appliance in this clinical setting.  All told, the oral appliance was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 45-year-old woman with a history of a vertical banded gastroplasty (VBG). Since the VBG the patient has experienced persistent erosions and reflux. The patient wishes to undergo a salvage operation involving the duodenal switch procedure. The Health Plan has denied authorization for the requested procedure, but has authorized a Roux-en-Y gastric bypass (RYGB).The surgeon embarking on revisional surgery after failed VBG needs the option of the duodenal switch procedure depending on the intraoperational findings. The upper abdomen may be so scarred that it would be difficult, if not impossible to take down the VBG and convert to RYGB. Additionally, the duodenal switch procedure offers the advantage of resecting the stomach away from the original site, reducing acid secretion, and creating more malabsorption. Furthermore, duodenal switch requires less postoperative dietary restrictions. Moreover, the recent report by Anthone, et al. demonstrates the safety and efficacy of the duodenal switch procedure. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a male with diagnoses of cerebral palsy, epilepsy with intractable complex partial seizures, mental retardation, expressive aphasia, gastroesophageal reflux disorder (GERD), subconjunctival hemorrhage of the right eye, H pylori infection, and constipation. An assessment done for a semi-electric hospital bed states the patients hospital bed is in good condition, but the head no longer elevates. The patients mother indicated that the patient has trouble breathing when positioned less than 30 degrees. The durable medical equipment (DME) assessment stated that the bed could be repaired in order for the patient to sleep safely. The assessment also noted that the patients shower chair was in good condition. Physical examination revealed normal respiration and no decubitus. The patient was capable of weight shifting independently. He required minimal assistance for bed mobility, sit to stand, and stand to sit, as well as chair to bed, and bed to chair transfers. His sitting balance was intact. The provider noted that the patient had an old hospital bed. The rails did not go up or down and the head of the bed could not be raised. He stated the patients head needs to be elevated to prevent aspiration and choking.  Based on the available documentation, the requested shower chair is not medically necessary. A shower chair is indicated for daily activities related to health and personal hygiene. However, this patients DME evaluation states that the patient has a shower chair that is four to five years old, in good condition, and there is no indication that it is unable to meet the patients hygiene needs. In addition, the semi-electric hospital bed is not medically necessary. The patient does not have a heart or a lung problem that requires head of the bed positioning. There is no need for a frequent or immediate position change. There is documentation that the patient is at risk of aspiration, however, the records do not support that the patients body positioning could not be obtained with wedges or support pillows. The documentation states that the patients current hospital bed can be repaired per the DME evaluation. Therefore, the request for a new bed exceeds the patient's medical needs. Therefore, the requested shower chair and semi-electric hospital bed are not medically necessary for treatment of this patients medical condition. 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 a licensed M.D. board certified in physical medicine and rehabilitation with subspecialty 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for Follicular Extraction Transplantation (FUE) Hair Transplantation Surgery for alopecia. Findings:  The physician reviewer found that a referral was made for a dermatology consult for hair transplantation, as the enrollee believes his lack of hair and resultant anxiety is causing his high blood pressure. The enrollee has androgenic alopecia, which is the most common cause of hair loss. Although literature supports the distressing effects of alopecia on health, such as anxiety and low self-esteem, literature does not support hair transplantation as the first-line therapy. Alopecia management involves a thorough assessment of an enrollees history, including nutritional status and risk factors, as well as physical exam including description and scalp biopsy. This is because malnutrition, vitamin deficiency, and risk factors, such as hair trauma are reversible causes of alopecia. Physical exam will also identify whether alopecia is solely due to androgenic alopecia or is exacerbated by a fungal infection. While literature supports hair transplantation as a more aesthetically pleasing, definitive treatment for severe alopecia, studies support non-surgical therapeutic modalities as a primary means of therapy in the early phases of hair loss. Non-surgical therapy includes medication and laser phototherapy. Studies support that advances in non-surgical medical management have allowed for stabilization of the hair loss process and partial re-growth. Review of the records indicates insufficient evidence of a comprehensive evaluation and work-up for the enrollees alopecia before considering hair implantation as a medical treatment option. Considering that surgical intervention is not the first-line therapy for treating this enrollees alopecia, Follicular Extraction Transplantation (FUE) Hair Transplantation Surgery is not medically necessary to treat the enrollees alopecia.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for leukocyte histamine release testing measures the amount of histamine released in vitro. Allergen extracts are added to the peripheral blood leukocytes of the patient being tested. Histamine is normally released as a consequence of the interaction of allergen with cell-bound immunoglobulin E (IgE) antibodies. If a patient is hypersensitive to a specific antigen, the leukocytes will release the histamine in vitro. However, there is a lack of peer-reviewed medical literature to support the clinical utility of this testing for diagnosis of this patients medical condition. The current standard of care to diagnose an autoimmune type of chronic urticaria, as suspected in this patient, includes a test measuring the presence of autoantibodies against the receptor to the constant region of IgE on mast cells and basophils. For these reasons, the leukocyte histamine release testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the leukocyte histamine release testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the leukocyte histamine release testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychotherapy services. The patient is variously diagnosed with major depression, recurrent, generalized anxiety disorder, obsessive compulsive disorder (OCD), BPAD unspecified, with impulsivity, risky behavior, and paranoid thinking. He also has a reported seizure disorder. By his own report, the patient had abused alcohol but had been sober for several months before receipt of the services at issue. He also reported having strained family relationships and stress at home. Upon referral from a Licensed Clinical Social Worker (LCSW) therapist to services elsewhere, the therapist wrote that the patients OCD had improved, that he had decreased impulsivity, and that he had no suicidal or homicidal ideation. The patient received psychotherapy services from a clinical psychologist who was located near the patients school during the period in question. The submitted documentation includes notes from six psychotherapy appointments. In this case, the submitted documentation does not reflect that the patient had a psychiatric emergency medical condition during the period that he received the services at issue. At the time of the patients referral to the clinical psychologist, the LCSW therapist indicated that the patient was not experiencing suicidal or homicidal ideation and did not present a risk of harm to himself or others. Furthermore, there is no indication in the psychotherapy notes for the initial appointment that the patient was either an immediate danger to himself or to others. In addition, there is no indication in the submitted documentation that the patient was unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder during the relevant period of time. During this period, the patient was either living at home or attending school successfully. The patients needs for food, clothing, and shelter were provided. Finally, there is no indication that any of the services at issue relate to a screening that was provided to determine whether a psychiatric emergency medical condition existed. Under these circumstances, the psychotherapy services provided to the patient on the dates of service at issue did not constitute psychiatric emergency services as defined by California law.Final Result: The reviewer determined that the services at issue were not psychiatric emergency services. Therefore, the Health Plans denial should be upheld.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma. Three physician reviewers found that per Torrego and colleagues, bronchial thermoplasty for patients with moderate to severe asthma can provide a modest clinical benefit in quality of life and lower rates of asthma exacerbations. Wahidi and Kraft reported that bronchial thermoplasty is an option for patients with severe asthma who continued to be symptomatic despite maximum medical treatment. However, there is a paucity of randomized controlled trials on patients with severe persistent asthma who experience more than three exacerbations of asthma in one year. This patients records document frequent exacerbations to include at least four to five times per year. Given the lack of data demonstrating superior health outcomes in this patient population, the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three 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:  One reviewer is board certified in pulmonary diseases with sub-specialty certification in critical care and sleep medicine and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in pulmonary diseases and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.