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

A 62-year-old transgender person has requested breast augmentation surgery for treatment of the enrollees gender identity disorder. Findings:  The physician reviewer found that in this patients case, the current state of her breast development is equivalent to that of a small-breasted genetically born female. The submitted documentation includes a report which documents breast and body changes due to hormone therapy. In the submitted photograph, there is some visible breast tissue present. As such, the patients presentation is consistent with hypomastia and is not an abnormal structure of the body. Thus, as breast augmentation is considered cosmetic and not medically necessary for small-breasted women, it is not reconstructive in nature or medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested acupuncture for the treatment of her low back pain. Findings:  The physician reviewer found that the patient has undergone physical therapy for her symptoms from the time of the injury until being discharged from physical therapy with regard to her low back. She appears to have continued with physical therapy for her neck and left shoulder symptoms, and was on disability, per the records reviewed. X-rays of the lumbar spine, pelvis and thoracic spine were normal.  An MRI of the lumbar spine showed moderate stenosis of L5/S1 and some annular fissures.  The patient was seen by a doctor who ordered the MRI and wanted to add acupuncture to her low back treatment. The patient continues to complain of low back symptoms, especially with regard to sitting, standing and bending.  This patient is still experiencing discomfort in the low back which limits her ability to work and/or perform activities of daily living.  Acupuncture has proven to be of benefit in situations such as this one. The requested acupuncture treatment is reasonable and may be of benefit in relieving this patients symptoms and enabling her to return to work and perform daily activities more easily.  A trial course of 8 to 10 treatments at a frequency of two to three times a week could be rendered with re-evaluation at the conclusion of the course of treatment.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 16-year-old male with a diagnosis of fragile X syndrome who has been receiving speech therapy secondary to global speech delays. He has been receiving speech therapy in the school system in a group setting and has also been receiving individual speech therapy in the private setting. The private speech therapist is recommending continued speech therapy once per week.  The Health Plan has denied authorization for past and future speech therapy citing a lack of medical necessity.In reviewing the speech therapists evaluation from April 2005 in comparison with the evaluation from September 2002, there is little documentation that the patient has made functional gains in his speech. The primary emphasis of the therapy is on expression of emotion and answering yes or no questions. At age 16, these are goals that cannot be achieved within a reasonable and predictable time period.  It appears cognitive issues are affecting the attainment of these goals and progress cannot be anticipated in a reasonable amount of time. The patients pragmatic/social language skills are being treated in a group setting within the school system. The submitted documentation does not demonstrate the medical necessity of past and future speech therapy in this case.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested residential treatment center (RTC) services and readmission with future services for treatment of the enrollees generalized anxiety disorder and mood disorder.  Findings:  The physician reviewer found that based on the records provided for review, RTC level of care services are not supported as medically necessary for treatment of this patients medical condition from the specified date and forward. The psychological report fails to document concern that the patient would be a danger to herself or others. Further, the provider noted that the patient is able to remain very calm in times of stress. A discharge form does not document that the patient has any high-risk behaviors or suicidal thoughts. In addition, the form states that the patient is slightly improved over admission but there is no narrative to support this assessment. All told, the medical records fail to provide evidence that the patient meets continued stay criteria for residential level of care. Therefore, the RTC services provided from the timeframe specified, and readmission with future RTC services, are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zydelig for treatment of the enrollees relapsed B-cell prolymphocytic leukemia/mantle cell lymphoma. Findings:  The physician reviewer found that this patient has advanced mantle cell lymphoma. There are very limited treatment options for patients  diagnosed with this disease, although some patients have long durable responses to chemotherapy. Like many difficult to treat cancers, it usually responds to initial chemotherapy but invariably relapses. In this patients clinical course where she has a good performance status, off label medications are available for use. There is data supporting Zydelig for the treatment of mantle cell lymphoma with good responses. Thus, Zydelig is medically necessary for the treatment of this patients medical condition. Final result: The reviewer determined that the requested medication 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 sub-specialty certification in medical oncology 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 Dupixent (dupilumab) subcutaneous solution prefilled syringe 300 mg/2 mL. Current medical literature supports the use and efficacy of the requested medication in this clinical setting. Bachert and colleagues report that in patients with chronic rhinosinusitis with nasal polyps, dupilumab reduced polyp size, sinus opacification, and severity of symptoms and was well tolerated. In this case, given the patients phenotype of chronic asthma, eosinophilia, nasal polyposis, and pansinusitis, the requested medication is medically indicated. Therefore, Dupixent (dupilumab) subcutaneous solution prefilled syringe 300 mg/2 mL is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 and in allergy and immunology 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 35-year-old male enrollee is requesting a custom fit, functional, anterior cruciate ligament brace for the treatment of the enrollee, who is status post right knee anterior cruciate ligament reconstruction with hamstring autograft and lateral meniscus repair. Findings:  The physician reviewer found that although the use of braces following anterior cruciate ligament surgery is common, evidence of their efficacy is lacking.  No significant difference between braced and unbraced groups has been found in several randomized, prospective studies. Some decrease in postoperative swelling and pain has been seen with the use of rehabilitation braces. However, at final follow-up after one to two years, there was no difference in motion or strength, and no difference was found with the use of functional braces. There is a lack of evidence in the literature to indicate the necessity of the equipment at issue.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested for speech therapy services for treatment of the enrollees speech disorder. Findings:  The physician reviewer found that he is a young preschool-aged child with severe stuttering disorder. Some theorists consider stuttering to be the result of subtle neurophysical dysfunctions resulting in disruption of the precision needed to produce speech. Stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma (see Ward). Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously. However, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category. They require therapy and counseling in order to recover from the disorder. For this latter group, if therapy is started early, the prognosis is favorable.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The composite score is then used to determine the level of care needed. Applying CALOCUS, this patient does not meet the criteria for RTC services provided. The patient has been at significant risk of harm (score 3) due to her history of suicidal behavior and excessive alcohol use. The patient has shown moderate functional impairment (score 3) given her conflict with her peers. The patient has significant comorbidity (score 3) considering her alcohol use disorder, PTSD, and depression. The patients recovery environment is moderately stressful (score 3) given her experienced with online harassment by her former best friend. The patients recovery environment is supportive (score 2) considering her parents engagement with treatment. The patient has exhibited poor response to treatment (score 4) with continued symptoms after over one year of outpatient therapy and medication management, followed by nearly two months of IOP treatment. The patient has been incompletely engaged in treatment (score 3) as her providers documented that she minimizes her alcohol use and depressive symptoms. This gives the patient a composite score of 21, which is consistent with medically monitored community based services. Per CALOCUS, services in this level of care include partial hospitalization, (and) intensive day treatment. In this case, patient does not meet eligibility criteria for a RTC level of care. Accordingly, 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 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: Upheld

A fifty-three year-old female with myelopathy, arthralgias and severe fatigue is requesting coverage of interferon alpha injections.  The patients treating neurologist reports the patient has partial reactivity to HTLV2 and low b12. The patient reports that the fatigue is better with interferon alpha injections.Reviewers Findings:The reviewing physician found there is no evidence that interferon-alpha has any role in the treatment of HTLV2 associated myelopathy. As such, treatment with interferon-alpha is of unproven efficacy in this clinical situation and is not medically indicated.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year, seven-month-old male enrollee has requested speech and language therapy for treatment of the enrollees developmental delays.  Findings:  The physician reviewer found that the patients medical records suggest that he has mild developmental delays. The patient began walking at 17 months, but was 4 weeks premature. The age-adjusted expectation for his development would place him walking at 16 months of age. This delay is still considered within normal limits for the onset of walking. Further, his communication skills appear to be relatively intact for his age. Based on the study by Coplan and Gleason, as well as other studies, it is likely that this young patient will progress in his language skills without intervention at this time. Thus, based on the clinical information provided, active speech and language therapy is not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture for treatment of the enrollees tinnitus.Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting.  The studies that support acupuncture as an effective therapy for chronic tinnitus are not based on evidence of rigorous randomized controlled trials. The medical research does not show statistical significant differences between the acupuncture group and the placebo group. Further research on this subject seems to be warranted but should be conducted according to the highest methodological standards.  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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for shoe orthotics for treatment of the enrollees bilateral foot pain. Findings:  The physician reviewer found that the submitted medical documentation noted that this patient has bilateral foot pain with diagnoses of posterior tibial tendinitis, peroneal tendinitis, sinus tarsitis, and questionable stress fracture of calcaneus. The use of custom orthotics is the standard of care for treatment of bilateral foot pain as experienced by this patent. Custom orthotics are used in podiatry frequently to correct the abnormal biomechanics of patients feet, thereby alleviating abnormal strains of tendons, muscles, and ligaments, such as in this case.  The correction of the abnormal biomechanics subsequently alleviates patients pain. In this particular case, her bilateral foot pain was well documented. This patient was diagnosed with bilateral feet pain, inflammation of the sinus tarsi and a questionable stress fracture of the calcaneus. Custom shoe orthotics will correct the abnormal biomechanics of this patients foot thereby alleviating her bilateral foot pain. Final Result: The reviewer determined that the requested devices 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 podiatry 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 authorization and coverage for a consultation for a Kyphoplasty. The submitted documentation does not support that the requested service is medically necessary. The California Technology Assessment Forum (CTAF) concluded that balloon kyphoplasty meets CTAF criteria for safety, effectiveness, and improvement in health outcomes for the treatment of recent (less than three months old) osteoporotic vertebral compression fractures confirmed by MRI. Balloon kyphoplasty does not meet CTAF criteria for the treatment of chronic (greater than three months old) osteoporotic, traumatic, or pathologic vertebral compression fractures.In this case, the patient presents with a history of vertebral compression fracture at T12 due to a fall. There is no evidence of osteoporosis or vertebral body neoplasms. She reports ongoing back pain, with functional limitations in walking tolerance due to back pain and spasms. Conservative treatment has included rest, medications, and a trial of bracing. There is imaging evidence of a subacute (approximately 70%) compression fracture with marrow edema involving the body of the T12 vertebra with mild retropulsion of the posterior superior margin of the fractured vertebra partially effacing the anterior subarachnoid space without cord compression or significant central canal stenosis. Current evidence-based medical guideline criteria for balloon kyphoplasty have not been met. There is no evidence of osteoporosis, and kyphoplasty is not supported for traumatic vertebral compression fractures. Under these circumstances, the requested consultation for kyphoplasty is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for laparoscopic radiofrequency ablation of fibroids. This patient has heavy bleeding, pelvic pain, and bulk symptoms. Ultrasound demonstrated that the patients fibroids are intramural and less than 6 cm. Standard options for treatment include hysterectomy, myomectomy, and uterine artery embolization. Radiofrequency ablation procedure is a less invasive alternative treatment for myomas of appropriate size and location. Researchers found that radiofrequency ablation of uterine fibroids reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates. Based on the peer-reviewed medical literature, the requested laparoscopic radiofrequency ablation of fibroids is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the Prometheus Anxer IFX diagnostic test. Anser IFX has not definitively demonstrated efficacy for the management of Crohns disease. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Another review reported that there is ongoing debate as to the relevance of antibodies to infliximab development in clinical care and that published studies on this topic lack uniform reporting of outcomeshigh risk of bias was present in all the included studies. In summary, current medical literature reports contradictory outcomes and lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies such as dose increase or change in medication based on those thresholds, and then definitively establish that use of Anser IFX improves outcome. All told, the Prometheus Anser IFX testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Prometheus Anser IFX testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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.