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

The parent of an 11-year-old female enrollee has requested in-home nursing care for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that the requested skilled nursing services are not medically necessary for this patient. Review of the submitted documentation including a comprehensive assessment on the date indicated reveals that the patients needs are custodial in nature and do not necessitate skilled nursing services. Assistance with activities of daily living such as eating, grooming, dressing, and provision of certain medications are considered custodial care. Additionally, although safety concerns are documented, skilled nursing services are not medically necessary to respond to these concerns as such issues are typically addressed by non-skilled caregivers or other custodial measures. All told, there is a lack of evidence that the patient has functional or medical needs that require a skilled nursing level of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of the jaw and an oral prosthesis.The current, well accepted, universally performed test to identify the presence or absence of temporomandibular disorder (TMD), or one of its subcategories, is a comprehensive evaluation of the patients history and clinical examination, and when indicated, select imaging such as magnetic resonance imaging (MRI) of the jaw. MRI in open and closed mouth positions is standard when evaluating for internal derangement. It provides the most information regarding the soft tissue structures and disk position. In this case, the patient has a history of jaw pain, and his oral surgeon has noted that the patient has limited opening, pain, and an examination that is consistent with internal derangement. Under these circumstances, MRI of the jaw is medically necessary to treat the patients medical condition.Splint therapy has been shown to be beneficial in patients with TMD and Myofascial pain. Splint therapy has been shown to decrease symptoms in 70 to 90% of cases. There are various types of splints used to treat myofascial pain, however, a single maxillary or mandibular splint is the well accepted method for treating such patients. In this case, the patient has jaw pain and suspected TMD, and an oral prosthesis is an appropriate treatment to accomplish a decrease in his symptoms. Accordingly, the requested oral prosthesis is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic esophageal sphincter augmentation procedure with placement of a sphincter device (CPT code 43284). Findings:  Two of the three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not demonstrate that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, laparoscopic esophageal sphincter augmentation procedure with placement of a sphincter device (CPT code 43284) is not likely to be more effective 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 50-year-old male enrollee has requested authorization and coverage for 600mg daily dosage of Wellbutrin (bupropion XL)for treatment of the enrollees depression.  Findings:  The physician reviewer found that in this patients case, the requested 600mg daily dosage of Wellbutrin (bupropion XL) is not medically necessary.  As per American Psychiatric Association guidelines, a number of strategies are available when a change in treatment plan is necessary.  The guidelines note that optimizing the medication dosage is a reasonable first step if the side effects are tolerable and the upper limit of a medication dose has not been reached.  The maximum daily dosage limits for Wellbutrin XL is 450mg per day.  The patient has requested coverage for 600mg daily dosage of Wellbutrin (bupropion XL), which exceeds this upper limit.  There is a disproportionate increase in seizure incidence with higher dosages.  Studies have shown the potential for hepatotoxicity with increased dosages of the requested medication.  The patients medical records note dysthymia.  Dysthymic patients may require more than three months of treatments before they demonstrate an adequate response. This suggests a more difficult course of illness which may warrant augmentation strategies beyond co-administered Buspar.  The current medical evidence does not support the requested medication dosage in this clinical situation.  All told, 600mg daily dosage of Wellbutrin (bupropion XL) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program services that were provided for 33 days. The Health Plan denied the request and reported that the services at issue were not medically necessary for the treatment of this patient. At issue is whether the intensive outpatient program services were medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that based on the records, the patient denied suicidal or homicidal ideation and did not have psychosis or any medical issues. There was no report of the patient requiring assistance with activities of daily living. She was cooperative with care and actively involved in her treatment. She was participating in her treatment plan and attending 12-step groups. The American Association of Community Psychiatrists Level of Care Utilization System is used to determine the necessary level of care for adults. The patient has a composite score of 10 to 11. This correlates with treatment in a community-based outpatient clinic setting. The medical evidence does not support the services at issue in this clinical setting. Therefore, the requested intensive outpatient program services that were provided for 33 days were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the World Health Organizations International Classification of Functioning, Disability and Health (known as ICF) is a classification of health and health-related domains. These domains are classified from body, individual and societal perspectives by means of two lists: 1) a list of body functions and structure; and 2) a list of domains of activity and participation. Since a patients functioning and disability occurs in a context, ICF also includes a list of environmental factors to be considered. The ICF acknowledges that every patient can experience a decrement in health and thereby experience some degree of disability. By shifting the focus from cause to impact, ICF suggests assessing all health conditions using a common measurement of disability. This definition places autism on the same spectrum of disability as laryngeal injury, traumatic brain injury, or stroke based on the similar deficits in speech experienced in patients with these conditions. Thus, based on the ICFs definition of health and disability, the requested speech therapy is necessary from a medical standpoint. Additionally, in applying Inkelas and colleagues criteria, this patients documented social communication deficits, echolalia, and decreased sustained conversations are functional deficits that are likely to benefit from skilled intervention. The literature is replete with data in support of young autistic patients obtaining clinical benefit from speech therapy services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested has authorization and coverage for acupuncture services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of back and shoulder pain.Finding: The request for acupuncture services is medically necessary and appropriate at this time.  The patient reported having shoulder pain, shoulder stiffness, back pain, and associated arm pain. There were symptoms of numbness and paresthesia.  Research supports the use of acupuncture for shoulder pain. Medical literature shows single point acupuncture in association with physiotherapy improves shoulder function and alleviates pain. Additionally, the improvement is accompanied by a reduction in the consumption of analgesics. Additionally, a study found that contralateral acupuncture in the treatment of chronic shoulder pain demonstrated beneficial effects in terms of pain and function.  According to medical literature, acupuncture is effective for the treatment of chronic musculoskeletal, headaches, and osteoarthritis pain. The documentation provided demonstrates that this patient has a musculoskeletal condition for which acupuncture is supported through research. Therefore, the requested services for acupuncture is medically necessary for the 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.Credentials/Qualifications: The reviewer is board certified in oriental 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 patient is a 35-year-old female, gravida 1, para 0, with a positive human papilloma virus (HPV) DNA probe. She underwent colposcopy with endocervical curettage (ECC) in August 2006. Biopsy revealed CIN III with abnormal vessels, or carcinoma in situ. The patient has reviewed the treatment alternatives with her provider and has submitted a request for total abdominal hysterectomy to the Health Plan. The Health Plan does not consider this procedure medically necessary, and has denied the patients request for authorization.Simply stated, hysterectomy (vaginal or abdominal) is the definitive treatment for CIN III with positive ECC. The patients choice of treatment is absolutely acceptable and consistent with the standard of care within the gynecologic community. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for surgery to install a plate to stabilize a broken collarbone for treatment of the enrollees fractured collarbone.Findings:  The physician reviewer found that the in this patients case, evidence based medical peer reviewed literature supports open reduction and plate fixation of acute displaced mid-shaft clavicular fracture as safe and effective. The risk of non-union is significantly lower after operative treatment than after non-operative treatment. This patient sustained a complex right clavicular fracture. X-rays showed a comminuted displaced fracture in the mid-clavicle with inferior displacement. The initial orthopedic provider discussed surgical and non-surgical options and indicated that the patient chose non-surgical treatment. Over the next two days, the patient reported significant pain with instability and desired surgical fixation of the clavicle fracture. There is current evidence based medical literature to support open reduction and plate fixation of this fracture to lower the risk of non-union. According to the documentation provided, this patient meets the surgical criteria for plate fixation given the complex right clavicular fracture and symptoms reported. Therefore, surgery to install a plate to stabilize the patients broken collarbone is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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: Upheld

A 42-year-old female enrollee has requested intensive outpatient services for the treatment of her eating disorder. Findings:  The physician reviewer found that the patient was indeed experiencing significant eating disorder issues in the recent past. Before starting intensive outpatient treatment, she was in a residential facility. The current program appears to be a follow-up of her residential care. However, the specific clinical information provided in the record reviewed is vague and does not demonstrate a clear and unambiguous need for intensive outpatient services. The patients clinical needs could have been safely and satisfactorily met by outpatient treatment, and she did not require intensive outpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for facial feminization surgery services genioplasty, rhinoplasty, and septoplasty. Researchers reported, Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. facial feminization surgery, gender reassignment surgery, or both) are associated with improved mental health-related quality of life. The World Professional Association for Transgender Health (WPATH) position statement notes, Non-genital surgical procedures are routinely performed notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The WPATH position statement also states, The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The medical evidence supports the requested services in this clinical setting. Therefore, facial feminization surgery services genioplasty, rhinoplasty, and septoplasty are medically necessary for the 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 psychiatry with expertise in transgender health 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 55-year-old female has requested a C-leg microprocessor controlled knee and related items for the treatment of above-the-knee amputation.  Findings:  Two physician reviewers found that the C-leg has not statistically demonstrated improved performance when compared to a conventional mechanical prosthesis. Furthermore, there is no statistically significant evidence to indicate that the C-leg will in fact prevent falls to a greater extent than a conventional leg or that it will result in increased activity levels for amputees as compared to the mechanical prosthesis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a continuous passive motion (CPM) device and for physical therapy. The medical literature and submitted documentation do not support the medical necessity of the continuous passive motion (CPM) device in this case. There is no demonstrated benefit of continuous passive motion used in the home setting following hip arthroscopy for any indication with regards to functional or health outcomes. In this case, the patient underwent left hip arthroscopy surgery but did not receive the hip CPM device until nine days later. There is no clear documentation related to the patients left hip range of motion postoperatively or whether, and how specifically, the CPM device was employed. Under these circumstances, the CPM device was not medically necessary for treatment of the enrollees medical condition.The submitted documentation does not support the medical necessity of the physical therapy provided to the patient. There may be a role for vestibular rehabilitation, and rehabilitation for concussion injuries and benign musculoskeletal spinal conditions in the short-term following multi-trauma. However, there is no proven role for these interventions in the long-term, especially for formal manual therapy interventions. In this case, at the start of physical therapy, the patient was more than 10 months distant from the motor vehicle accident that caused her injuries. There was no basis for ongoing therapy on an empiric basis for the patients conditions. There were no indications that she had impairments that would have precluded a fully independent program as of that time. There were also no objective indications of benefit for ongoing therapy as of that time. Although the patient continued to have symptoms, no marginal difference in clinical course or outcomes would have been reasonably expected with ongoing therapies versus an independent program at that time. Additionally, despite the therapies that were rendered, the patient continued to have persistent significant symptoms, without noted improvement in her condition that could be reasonably attributable to the interventions. Accordingly, the physical therapy provided to the patient was not medically necessary for treatment of the enrollees 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 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 has requested authorization and coverage for bilateral Euflexxa injections, one a week for 3 weeks. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis. A review of the records indicates that the enrollee is diagnosed with primary osteoarthritis of both knees, and is status post bilateral arthroscopic partial lateral Meniscectomy. Progress notes indicated the enrollee had presented with bilateral knee pain, and is unable to perform activities of daily living comfortably now due to her condition. The enrollee reported that past lubricant injections had provided pain relief lasting 6 months. The provider recommended bilateral knee Euflexxa injections, weekly, for 3 weeks. The submitted documentation supports the medical necessity of the requested treatment. Given the history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intraarticular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. This shows that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, the requested Euflexxa injections one a week for three weeks into both knees is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested treatment 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.