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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage 20 hours a week of applied behavioral analysis (ABA) services. Based on the presented information, the Council of Autism Service Providers (CASP) and ABA Coding Coalition treatment guidelines, and the medical necessity criteria outlined by Papatola and Lustig, the requested ABA services are not medically necessary for treatment of this patient. The records provided for review do not include an updated assessment information regarding current levels of functioning, skill deficits, or challenging behaviors that are to be addressed during treatment. Per the  ABA Coding Coalition, without assessment and an individualized treatment plan, the focus of the ABA services remains unknown. Similarly, the focus of the requested ABA services, which is typically reserved for targeting specific challenging behaviors or a limited number of key functional skills, cannot be established based on the available documentation. Further, the requested 20 hours per week of ABA services does not meet the medical necessity criteria outlined by Papatola and Lustig. Per the authors, medical necessity criteria includes a) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) autism diagnosis supported by symptoms, b) symptoms of diagnosis causing impairment, c) motivation for change exemplified by family involvement, d) interventions are evidence-based and consistent for type, frequency, and duration of treatment, e) goals are constructed with patients family, f) outcomes are measurable, g) occurs in least restrictive environment, h) required for purposes other than convenience of patient or provider, i) measurable reduction in symptoms, j) symptoms are manageable, and k) day-to-day functioning has improved over baseline. The request fails to meet criteria e), f), h), i), j), and k). The patient should receive further assessment to inform a treatment plan that is individualized to their needs to better identify the level of support warranted. Moreover, the requested ABA services are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Based on the available documentation, the requested 20 hours a week of ABA services 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 a licensed B.C.B.A, board certified in psychology, 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 45-year-old female enrollee has requested for a panniculectomy/abdominoplasty for the treatment of her low back pain. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the requested procedure is reconstructive in nature. The photographs provided reveal a patient with an abdominal pannus that does not cover the mons pubis and barely reaches to the inguinal ligament. Thus, the amount of excess skin is not so great as to be considered abnormal. Nor is there evidence that the excess skin is visibly affected by disease or infection. As such, the patients excess skin condition does not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. Therefore, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Regarding whether the requested surgery is indicated based on general concepts of medical necessity, the submitted evidence does not demonstrate a functional impairment requiring surgical intervention. The patients plastic surgeon notes that, she states that the pulling weight of the abdominal pannus causes constant low back pain making daily activities difficult. There is lack of documentation of physical therapy, orthopedic or neurologic evaluations, and conservative treatment for the patients back pain. In addition, a loss of functioning is not documented. Furthermore, the submitted photographs do not document skin rashes, intertrigo, skin ulcerations, or hyperpigmentation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old male requested authorization and coverage of intradiscal electrothermal therapy (IDET) for the treatment of back pain.  The health plan denied the enrollees request indicating that IDET is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that IDET is not likely to be more beneficial for treatment of the enrollees back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested a real-time remote heart monitor for evaluation of her atrial fibrillation.  Findings:  Two physician reviewers found that the requested device is likely to be more efficacious than other options for evaluating this patient.  She has had recurrent atrial fibrillation, failed multiple drug therapies and is status post atrial fibrillation ablation.  Given that some episodes of atrial fibrillation may be episodic and asymptomatic, more prolonged monitoring with a real-time monitor as follow-up to the ablative treatment procedure is reasonable in this clinical setting.  In this patients case, the real-time remote monitor will be used to assess for recurrent atrial fibrillation prior to consideration of discontinuation of anticoagulation therapy.  It is important to know if asymptomatic paroxysmal atrial fibrillation is persistent, as discontinuation of anticoagulation therapy in patients with recurrent paroxysmal atrial fibrillation can lead to a significant increase in risk for cardiac embolization and stroke.  Therefore, the requested real-time remote heart monitor is likely to be more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested bariatric surgery (duodenal switch) for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services at this time.  Although this patient has clinically severe obesity with a body mass index of 37.23, the medical necessity of the requested services has not been documented at this time.  The medical records do not include documentation of a dietary evaluation showing that the patient is an appropriate candidate for the requested surgery.  In a letter on the said date the provider noted that the patient has tried and failed multiple regimens for weight control, including phentermine.  The submitted records did not provide information regarding these prior regimens.  In sum, a complete dietary evaluation indicating likelihood of compliance and documentation of weight loss efforts are required in order to establish the necessity of the requested bariatric surgery (duodenal switch).  All told, the requested services are not indicated for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for continued speech therapy for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that as discussed by Law and colleagues in their extensive meta-analysis, there are many years of medical literature supporting the need for speech therapy intervention in this patient subset. Further, Sharp and Hillenbrand reviewed the current status of speech therapy in this young population and found that speech therapy is effective in remediating the problems associated with speech delay. The controlled study by Goorhuis-Brouwer and Knijff reports that children with significant cognitive impairment will benefit from speech therapy. Thus, the literature strongly supports the medical necessity of speech therapy for this patient.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 59-year-old woman with long-standing knee pain due to osteoarthritis. She received a series of Synvisc injections in October 2004 with good results. In July 2005, the patient underwent a repeat course of Synvisc injections. The patient has requested coverage for these injections. The Health Plan indicates a repeat course of Synvisc was not medically necessary for treatment of the patients condition.Synvisc injections have been proven to be helpful for this patient in obliterating the pain caused by her osteoarthritis. Given the positive results of the first series one year ago, it was medically reasonable to provide a second series to treat her pain. The only other alternative for this patient would be knee-replacement surgery. As such, a repeat course of Synvisc injections was medically appropriate and indicated in this case. Therefore, I have determined the injections at issue were 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 patient has hereditary angioedema with positive laboratory tests. The patient was provided with a sample of Firazyr for any future angioedema attacks. The patient reported shortness of breath and chest tightness. The patients C4 complement and C1 inhibitor quantitative levels were noted to be low. The patient has been treated with prednisone, Symbicort, and albuterol, without improvement. The patient has requested authorization and coverage for Firazyr (icatibant 30 mg/ 3 mL syringe). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Firazyr (icatibant 30 mg/ 3 mL syringe) is medically necessary for the treatment of this patient. Tourangeau and colleagues reported, C1 inhibitor (C1INH) has recently been approved in the United States for the treatment of acute attacks in hereditary angioedema (HAE) patients. The literature suggests that treatment with C1INH is most effective when administered early in an attack. Home infusion of C1INH allows for the earliest possible intervention since patients can initiate therapy at the first sign of symptoms. The authors also noted, Icatibant, a bradykinin B2 receptor antagonist administered by subcutaneous injection, was approved for treatment of acute attacks in Europe in 2008 and in the United States in 2011. Longhurst and colleagues reported, Experience shows that access to self or assisted infusion with C1INH reduces severity and duration of attacks, improves HAE-related quality of life, reduces time off work, education or domestic duties, is safe, and is very popular with participants. The medical evidence supports the requested medication in this clinical setting. Therefore, Firazyr (icatibant 30 mg/ 3 mL syringe) 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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Nutropin AQ Nuspin for treatment of the enrollees short stature. Findings: The physician reviewer found that the patients height is not more than two standard deviations below the mean for age and gender, there is no evidence of growth deceleration, and his bone age was normal. The patient has no known morphological abnormalities of the pituitary gland. The patients poor response to provocative growth hormone (GH) testing does not indicate that he is GH deficient, as only four serial blood samples were obtained over a period of 90 minutes for both provocative agents. Provocative testing has poor sensitivity and specificity for the diagnosis of GH deficiency, particularly in a male patient who has delayed pubertal development who is not primed with sex steroids. All told, the requested Nutropin AQ Nuspin 20 mg is not medically necessary for treatment of this 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 pediatrics with sub-specialty certification 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

A 58-year-old female enrollee requested authorization and coverage of Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization. Findings:  The physician reviewer found that Encephalopathy describes any diffuse disease of the brain that alters brain function or structure, and its hallmark is an altered mental state. When a patient presents to the emergency department with altered mental status, three broad categories of diagnosis should be considered: delirium, coma, and dementia. Altered mental status fundamentally involves changes in a persons alertness, attention, memory, and/or awareness, and its etiology may consist of five broad categories including infections, metabolic or toxic encephalopathies, neurologic causes, cardiopulmonary causes, and drug-related causes. Treatment of altered mental status is targeted at the underlying cause. Altered mental status has a relatively high mortality rate, and the disposition for most patients from the emergency room is admission to the hospital for further evaluation and management. Only patients with readily reversible causes of mental status changes, a clear cause of the episode that is treated and reversed, appropriate home care and physician follow-up, and who are back to baseline mental status may be discharged safely. Chen and colleagues note that some stroke types can present with encephalopathy or even bilateral deficits. Kernan and colleagues note that guidelines for the management of acute stroke recommend hospitalization for a work-up and treatment of underlying causes. In this case, the patient presented with confusion and acute encephalopathy. An initial work-up showed multiple metabolic abnormalities and a subsequent work-up showed multiple bilateral acute strokes. In this clinical setting, given that hospital admission was indicated for evaluation and management of the patient's condition, the services at issue were medically indicated. Therefore, inpatient hospitalization provided was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Upheld

The patient is a 51-year-old woman with a long-standing history of foot pain. Physical exam revealed tenderness over the MP joint of the great toe and discomfort on the extreme of dorsiflexion and plantar flexion. X-rays showed some narrowing of the MP joint. In June 2006 the patient received a steroid injection to the MP joint, which provided some relief. She is seeking authorization and coverage for a CT scan for further evaluation of her foot/toe pain. The Health Plan has denied this request citing a lack of medical necessity.The patient appears to have arthritis in the great toe. Arthritis is evident on the plain films and an injection helped to alleviate some of her pain. There is no history of trauma. A CT scan will not provide more information than has already been obtained through x-rays. As such, there is insufficient evidence that a CT scan is clinically indicated at this time. Accordingly, I have determined the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Soma. The American Pain Society (APS) reported a lack of evidence supporting the safety and efficacy of Soma for treatment of low back pain. The APS guidelines reported that the current data has shown benefit with Flexeril as a short-term treatment. Further, the APS cautioned that the potential adverse effects from the long-term use of skeletal muscle relaxants include sedation, addictive potential, and hepatotoxicity. One review concluded that, opioids, the benzodiazepines and carisoprodol alone or in combination are capable of inducing respiratory depression. In this case, the patient has underlying COPD with chronic low back pain and radiculopathy. She has been treated with both Soma and Norco in the past. Considering the patients diagnosis of COPD, the concurrent use of Soma with Norco would increase her risk of respiratory depression. Further, there is a lack of evidence in the medical literature that demonstrates the efficacy of Soma for long-term use in chronic low back pain. The risks in this case outweigh any potential benefit associated with Soma. Therefore, Soma is not medically necessary for treatment of this patient. 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 anesthesiology with subspecialty certification in pain management 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 32-year-old male enrollee requested authorization and coverage of the medication Lotronex. The Health Plan denied the request indicating that the medication is not medically necessary for treatment of the enrollees gastrointestinal problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis examinations for evaluation of the enrollees history of breast cancer. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. With regard to this patient, the tomosynthesis images of the 5/4/16 were available for review at the time of the diagnostic study of 5/10/16 and likely added nothing of value to the magnification views obtained on that date. Thus, the addition of tomosynthesis as part of the right diagnostic mammogram of 5/10/16 likely added nothing of value. Final Result: Two reviewers determined that a portion of the diagnostic procedures at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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 54-year-old male enrollee has requested Nexium 40 mg for the treatment of his gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. PPIs inhibit gastric acid secretion and raise intragastric pH, decreasing the damaging potential of the refluxate. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. The majority of patients will respond to once daily dosing, achieving healing of erosive esophagitis and symptom relief, regardless of the PPI chosen for initial therapy. Some patients, in particular those with extraesophageal symptoms or complicated disease, need more than a single daily dose. Interpatient variability has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles. The alternatives offered by the Health Plan are safe and effective and are reasonable choices for initial therapy. The Health Plan requires that the patient be given a trial of omeprazole, Prevacid and/or Protonix prior to coverage for Nexium. This is medically reasonable and appropriate.