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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services for rehabilitation services including physical therapy, occupational therapy, and speech therapy. Dementia is progressive and results in various adverse outcomes such as impaired social participation, compromised self-care abilities, and increased hospitalizations. Management options include redirection, structured care and support, involvement in stimulating activities, cholinesterase inhibitors, and reducing unnecessary polypharmacy. In this case, the patient has a history of multiple, chronic brain insults with dementia, manifested by severe cognitive deficits affecting domains such as memory, sensorium, and safety awareness. She also has severe physical impairments. She has undergone an extensive trial of post-acute inpatient rehabilitation to optimize function and care. She remains primarily dependent for care and mobility. She has plateaued with respect to the benefits expected from formal rehabilitation interventions and she requires custodial level of care. This level of care can be met in the community in an appropriate environment with caregiver support, or in a long-term care institutional setting if a community setting is not feasible. The patient does not require ongoing SNF level services with ongoing physical therapy, occupational therapy, or speech therapy. Therefore, the requested SNF services for rehabilitation services including physical therapy, occupational therapy, and speech therapy are 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 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 eight weeks of Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Two physician reiewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given these findings, the requested eight week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for one-to-one applied behavior analysis (ABA) program, 40 hours per week, and a behavioral aide 5.5 hours per day. ABA therapy has been identified as the most evidence-based treatment for individuals with autism. The Behavior Analysis Certification Board (BACB) indicates that treatment for autism can be focused (25 hours or less per week), or comprehensive (30 to 40 hours per week). The BACB notes that behavior that threatens the health or safety of the patient or that constitutes a barrier to quality of life should result in more intensive ABA services. In this case, it is not clear from the data presented that the patient has behavioral excesses that pose a threat to his safety or constitute a danger to himself or others. Specifically, the provider report dated October 2018 noted the current target behavior to be emotional dysregulation, which was defined at school as frequent peer altercations and intimidation, all of which have decreased over time since baseline data was collected in March 2017. Finally, research support for intensive ABA therapy provided to children older than seven years of age is mixed. Studies indicate that younger participants aged two through seven show a greater benefit from increased treatment hours when compared to older participants. This provides additional support for maintaining the current number hours approved in this patients case. In sum, the hours previously approved are sufficient for the patient, and increased ABA therapy is not medically necessary. The patient does not present with the type or intensity of problematic behaviors that warrant more intensive support. Therefore, the requested one-to-one applied behavior analysis (ABA) program, 40 hours per week, and a behavioral aide 5.5 hours per day were not and are not medically necessary for the 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 a board certified behavior analyst and licensed psychologist 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 parent of an enrollee has requested speech therapy for treatment of the enrollees mixed expressive/receptive language delay.  The physician review found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. The patients most recent speech therapy evaluation evaluated expressive and receptive language, but did not include pragmatic language testing. An earlier speech therapy evaluation revealed the patient has deficits in pragmatic or social language skills. Many children with ADHD have social and communication deficits. The study by Cordier and colleagues examined pragmatic language exhibited in children with ADHD and found that a play-based intervention did help improve pragmatic skills. This patient has pragmatic language deficits, but her expressive and receptive language has improved and she no longer requires individual speech therapy. Many of her speech therapy goals that have not been met are social or pragmatic language goals and should be addressed in a group with her peers than in individual interventions with an adult. For the reasons stated, speech therapy is not medically necessary in this clinical setting.  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 pediatrics with sub-specialty certification in developmental and behavioral 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

Nature of Statutory Criteria/Case Summary:An enrollee has requested laser hair removal for treatment of the enrollees gender dysphoria. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in a female in areas that are normally found in males. The abnormal hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of this patient. The requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. It would be abnormal for a female to have terminal hair on the face. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. In order to correct the patients abnormal appearance or give the patient a normal appearance to the extent possible, facial laser hair removal is necessary. These treatments will create a more feminine facial appearance. Moreover, the requested services are indicated to improve the patients emotional function. Therefore, the requested facial laser hair removal is medically necessary. For the reasons stated above, the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition.Final Result:The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:The 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral nerve block injections (greater occipital nerve) and other peripheral nerve or branch. The International Headache Society (IHS) describes occipital neuralgia as paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distributions of the greater, lesser and/or third occipital nerves, noting that the pain may be unilateral or bilateral with radiation into the temple or even behind the eye commonly triggered by head movements. The IHS notes that part of the diagnostic criteria is that tenderness to palpation  and pain are eased temporarily by local anesthetic block of the affected nerves. In a prospective study on the effectiveness of treatment of occipital neuralgia using nerve block techniques, Jukys and ustickas reported that occipital nerve block with a local anesthetic and corticosteroids provided a safe, technically simple, and effective treatment method that carries a minimal risk of side effects for patients with medically refractory occipital neuralgia. In this case, the patients symptoms are suggestive of occipital neuralgia. Given that occipital nerve blocks can aid in both diagnosis and treatment of occipital neuralgia and are supported in current medical literature as a safe and effective method for pain management, bilateral nerve block injections (greater occipital nerve) are likely to be more beneficial for treatment of the patients condition than any available standard therapy. Given that other peripheral nerve or branch does not appear to pertain, other peripheral nerve or branch are not likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bilateral nerve block injections (greater occipital nerve) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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: An enrollee has requested reimbursement for the genetic testing. The American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing in this clinical setting. Rather, the guidelines recommend application of standard risk factors and lipid profiling to direct decisions regarding lipid management. The guidelines have shifted away from specific target values and emphasize use of the pooled risk score analysis for treatment decisions. Moreover, there is a lack of scientific data supporting a role for prothrombin factor II and MTHFR mutations. For these reasons, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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

A 23-year-old female enrollee requested OB/GYN services provided on an emergent basis. Findings:  The physician reviewer found that based upon the documentation provided, there was no documentation of acute symptomatology or deterioration in health (e.g., diabetic coma) that would cause a prudent layperson to seek treatment on an immediate basis. The services were scheduled in advance and took place over a 21-day period. There were not delivered on an imminent or immediate basis to address an acute medical issue. While the services the patient received in Nevada were appropriate and indicated, they were not for treatment of an emergency medical condition.  The patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested occupational therapy and sensory integration occupational therapy for treatment of the enrollees autism spectrum disorder.   The physician reviewer found that in this case, traditional OT is not medically necessary as the patients fine motor skills are in the average range. However, sensory integration OT is medically necessary for treatment of the patients medical condition. According to the American Academy of Pediatrics Traditional occupational therapy often is provided to promote development of self-care skills (eg, dressing, manipulating fasteners, using utensils, personal hygiene) and academic skills (eg, cutting with scissors, writing). Occupational therapists also may assist in promoting development of play skills, modifying classroom materials and routines to improve attention and organization, and providing prevocational training. Sensory integration (SI) therapy often is used alone or as part of a broader program of occupational therapy for children with ASDs. The goal of SI therapy is to address deficits in neurologic processing and integration of sensory information to improve the individuals ability to interact with the environment. According to a paper by Roley  and colleagues, Sensory activities may be helpful as part of an overall program that uses desired sensory experiences to calm the child, reinforce a desired behavior, or help with transitions between activities. According to the documentation submitted for review, OT sensory integration therapy has been effective for this patient with a reported worsening of maladaptive behaviors when OT sensory integration therapy is reduced. In this case, sensory integration OT is medically necessary for treatment of the patients maladaptive behaviors including wandering, self-injury and aggression to others. 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 with sub-specialty certification in developmental and behavioral 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 patient is a 42-year-old female five years postoperative from craniotomy, which was performed to salvage a bleeding intracranial aneurysm that left the patient with multiple cranial nerve deficits on the ipsilateral side of her face. The submitted documentation indicates the only restorative procedures performed were placement of weight in the left upper eyelid to protect the eye, and augmentation of the left vocal cord to prevent aspiration and improve phonation. The patient has requested authorization for a plastic surgery consultation, which was determined by the Health Plan to be cosmetic and not medically necessary.The record lacks evidence of any discussion of facial reanimation or possible need for protection of facial function (drooling, dry eye, corneal ulceration, intraoral trauma from chewing, etc.) subsequent to the craniotomy. Plastic, otolaryngological, and maxillofacial surgeons are trained to evaluate and treat these problems. Whether the patient would benefit from nerve cable cross facial grafts or dynamic or static sling procedures cannot be determined without the appropriate consultation. The requested consultation is reconstructive in nature under California law and should be authorized.  Based upon the information set forth above, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg for treatment of the enrollees short stature. Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the patients medical condition. The patient has short stature with an adult predicted height that is 3 SDs below the mean for age and gender. His IGF-1 level was normal for age and there is no supporting evidence that he has growth hormone deficiency. In addition, there is no information provided that all other causes of the patients short stature, including nutritional deficiency, underlying systemic disease, and malabsorption, have been ruled out. Thus, based on the documentation submitted for review, it has not established that the request for Nutropin AQ Nuspin 20 mg is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication 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 pediatric endocrinology 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 reimbursement for the cardiologist consultation for evaluation of the enrollees heart murmur. Findings:  The physician reviewer found that in this circumstance thorough screening for signs of inherited connective tissue disease by a cardiologist was medically necessary and appropriate, especially when there are physical manifestations to raise suspicion. In this case, there was documented hyperextensibility and concern over abnormal heart sounds. Moreover, the cardiologists impression included abnormal findings not previously identified and assessed for potential critical findings of aortic dilation not previously addressed. Therefore, the cardiologist consultation was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.