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

A 28-year-old male enrollee has requested substance abuse inpatient care and acute detoxification for the treatment of his polysubstance dependence. Findings:  The physician reviewer found that the submitted clinical documentation does not demonstrate the medical necessity for continued acute inpatient/detoxification treatment. There is no report of a physical examination or vital signs documenting that the patient was unstable from a medical standpoint as of the last authorized date of service. In addition, although the records provide limited details regarding the detoxification protocol, it appears the patient had received five days of detoxification services. By the end of the period at issue, the patient reported feeling physical improvement. Thus, the submitted evidence does not establish that the patient was experiencing significant withdrawal symptoms during the period in question such that continued acute inpatient/detoxification services were required.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensive outpatient treatment services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Based on the documentation provided, specialty services at the intensive outpatient program level of care were indicated as the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  During the disputed timeframe, the patient was engaged in active treatment delivered in accordance with a multidisciplinary treatment plan.  Despite these interventions, the patient continued to struggle.  Treatment thereafter emphasized transitional planning and included closure sessions aimed at facilitating a smooth and successful transition to outpatient care.  However, intensive outpatient program treatment was no longer reasonably expected to improve her condition.  All told, intensive outpatient treatment services initially provided were medically necessary, but not thereafter.  Final Result: The physician reviewer determined that the services at issue were 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 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 four-year-old male enrollee has requested ongoing occupational therapy for two, one-hour sessions per week for treatment of the enrollees autism. Findings:  The physician reviewer found that according to the Guidelines for Autism by the American Academy of Neurology and Child Neurology Society developed in 2000, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. An occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. Thus, occupational therapy in this patient population is standard of care in the community. In the case of this patient, indications for medically necessary occupational therapy are met by this patient in that the requested therapy is aimed at improving and adapting function and the patient has shown evidence of practical improvement with prior therapy based on the progress notes provided. Given this patients ongoing functional deficits, the requested occupational therapy is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Hyalgan injections for both knees. Knee hyaluronic acid injection for osteoarthritic pain is not a first-line treatment and is typically recommended only after lower risk treatments such as independent exercise, weight loss and over-the-counter medications have failed. In this patients case, there is no documentation of knee osteoarthritis by imaging studies. Moreover, the patient is taking high-dose opioids and benzodiazepines. There is no reasonable expectation viscosupplementation with hyaluronic acid would bring about substantial pain relief in this patient in this clinical setting. Thus, the requested Hyalgan injections for both knees are not supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Jublia medication for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Jublia is U.S. Food and Drug Administration (FDA) approved for the topical treatment of onychomycosis of the toenails due to Trichophyton rubrum and Trichophyton mentagrophytes.  This patient has failed treatment with antifungal medications, topical laser treatments and topical antifungal treatment.  Therefore, Jublia medication is medically indicated 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 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 has requested approval for gastric bypass surgery for treatment of her obstructive sleep apnea, hypertension, and gastroesophageal reflux disease.   Findings:  The physician reviewer found that based on review of the available records, the patient meets all of the standard nationally accepted criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. This patient is an adult over 18 years of age with a BMI of 36 with documentation of sleep apnea, and hypertension. This patient therefore meets the definition of clinically severe obesity. In addition, she has failed dietary efforts in the past and completed thorough dietary and behavioral evaluations that did not reveal any obvious dietary, medical or behavioral barriers to surgery. Consistent with these findings, the requested surgery, gastric bypass surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested two 30-minute sessions per week of speech therapy for treatment of the enrollees severe expressive language impairment and moderate receptive language impairment.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient has significant delays in receptive and expressive speech/language skills that negatively impact his ability to express his needs and interact with peers and adults.  At 19 months of age, objective testing demonstrated language comprehension at the 12-month level and language expression at the nine-month level. The literature supports therapeutic intervention for children such as this patient. All told, two 30-minute sessions per week of speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested 13 hours per week of applied behavioral analysis (ABA) therapy and two hours per week of oversight for treatment of the enrollees autism and global delays.  Findings:  The physician reviewer found that the correlation between treatment outcomes and treatment intensity is well documented. In a recent article on the efficacy of ABA, the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. Per the records, the patient appears to have made progress in many areas, but continues to struggle with problematic behaviors which include vocal and physical stereotypy, peer interactions, lack of generalization of skills across environments, transitions and safety awareness and elopement. Failure to improve these behaviors not only puts the patient at an increased risk for injury, but also makes it increasingly difficult to be successful in more generalized environments. The current medical evidence supports the services at issue in this clinical setting. Final Result: The reviewers determined that the services at issue were and 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 pediatrics with sub-specialty certification in developmental-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: Experimental/Investigational
Decision: Upheld

A 20-year-old male enrollee has requested Ilaris (canakinumab) injections for treatment of his bilateral chronic uveitis. Findings:  Two physician reviewers found that the current literature does not reveal that the safety and effectiveness of canakinumab in treating anterior uveitis has been adequately established.  The use of canakinumab in treating anterior uveitis must then be considered off-label and of unproven efficacy in this setting. At this time, the scientific data does not establish that canakinumab is likely to be more beneficial than any of the currently available standard treatments in this setting.  As such, the Health Plans denial of authorization for use of canakinumab was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old female with a body mass index of 41.8. She has documented comorbid conditions. She has also been diagnosed with myasthenia gravis. The patients primary care provider indicates the patient has been on steroids at times for control of her symptoms. At issue is whether gastric bypass surgery is medically necessary for treatment of the patients morbid obesity. With a BMI of 41.8 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the best long-term outcome for the obese. Based upon the information provided, weight loss surgery is medically necessary to treat the patients morbid obesity. There is concern, however, about the use of steroids for treatment of the patients myasthenia gravis. Steroid use can predispose the patient to gastric ulcers, and once Roux-en-Y gastric bypass is performed the stomach can no longer be accessed for examination and intervention if there is a problem. Therefore, the patients providers should determine whether the use of steroids would preclude Roux-en-Y gastric bypass in favor of the duodenal switch procedure.   As set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old female enrollee has requested for treatment of the enrollees articulation disorder.  Findings:  The physician reviewer found that there is no evidence presented in the documentation supporting a medical need for speech therapy. There was no supportive documentation from the pediatrician indicating an assessment of a medical condition related to an on-going articulation disorder. After only a few speech therapy sessions the sound production problems had been alleviated. This suggests a self-correcting skill delay that has no medical basis and would have resolved through normal progression.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee is a 46-year-old female who is requesting retreatment with Rituxan infusion therapy for the treatment of her rheumatoid arthritis. Findings:  Two physician reviewers found that while studies in peer-reviewed journals have documented the efficacy of retreatment of Rituxan after six months for rheumatoid arthritis, there is no specified schedule for repeat Rituxan infusions; the need for retreatment depends on the individual patient presentation. In this case, the records fail to document that the patient is having a flare of rheumatoid arthritis. Her only symptom is morning stiffness and the severity of the stiffness is not documented. As such, it has not been demonstrated that retreatment with Rituxan is warranted in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female requested authorization and coverage of a bone density test for the treatment of breast cancer.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested test is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation therapy. Findings:  Two physician reviewers found that the patient has major depressive disorder.  Her psychiatric history is significant for two prior suicide attempts.  The patients medications have included Prozac, Wellbutrin, Gabitril, Cytomel, lorazepam, Adderall, Norco, Abilify, Zoloft, Paxil, Cymbalta, Effexor, Elavil, Buspar, Lamictal, desipramine, and imipramine.  Her symptoms include fatigue, severe anxiety, sadness, and hopelessness.  The patient has requested coverage for transcranial magnetic stimulation therapy.  In this clinical setting, transcranial magnetic stimulation is not likely to be more effective than other treatment options.  Electroconvulsive therapy remains the gold standard for refractory depression.  American Psychiatric Association guidelines note that treatment of refractory depression may include augmentation strategies with medications and psychotherapy.  While this patients history reflects augmentation strategies, there is no documentation of the use of monoamine oxidase inhibitors or alternate mood stabilizers, such as lithium.  Thus, the requested services are not likely to be more effective than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested weekly outpatient mental health therapy for treatment of his generalized anxiety disorder. Findings:  The physician reviewer found that this patient is a typically high-functioning individual who has severe psychosocial stresses and is symptomatic with anxiety and dysphoria. He has been treated with a treatment regimen consisting of anxiolytic and outpatient therapy sessions. The patient finds weekly therapy helpful to his anxiety and feelings. At less frequent visits, he was more symptomatic. Consistent with the American Psychiatric Association (APA) treatment guidelines, weekly psychotherapy is within the standard of practice given this patients symptoms and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees receptive and expressive language disorder. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25 % (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Approximately half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders and children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, speech therapy is medically necessary in this patients case.
Appeal type: Urgent Care
Decision: Overturned

The parent of a then 15-year-old female enrollee has requested urgent care services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that this patient experienced worsening of her original symptoms and was, in fact, diagnosed at re-examination with an infection warranting treatment with an antibiotic. This physical finding was not present at her initial urgent care visit. This constitutes a deterioration of her medical condition and an urgent clinical situation as judged by layperson criteria, as the patient had been advised to return to urgent care if her symptoms worsened. A prudent layperson in the patients circumstances would reasonably expect that the worsening of her symptoms constituted an urgent medical situation.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the brachytherapy. The standard of care for basal cell carcinoma is typically local destruction or surgical removal, including electrodessication and curettage, elliptical excision, or Mohs micrographic surgery. Brachytherapy may be an option for shallow, widespread lesions, or lesions at anatomic sites that lie immediately above structures vulnerable to irradiation. There are significant limitations in the use of brachytherapy for treatment of basal cell carcinoma. Specifically, the tumors that respond best with the lowest rates of recurrence are primary, superficial, and small. Most studies have found that adequate radiation dosage with brachytherapy cannot be delivered at depths much greater than 2 mm, making the treatment of infiltrative tumors impractical. This patient has a history of basal cell carcinoma with a prior history of skin cancer. The peer-reviewed medical literature does not support the use of brachytherapy for treatment of this patients basal cell carcinoma. In conclusion, the brachytherapy was not likely to be more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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 dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested Botox injections for treatment of her migraine headache.  Findings:  The physician reviewer found that this patient carries a diagnosis of chronic migraine.  The medical records show clinical features consistent with the diagnosis.  She has failed several prior preventive medications.  The clinical notes indicate a response to Botox injections, with a reduction in headache frequency.  The current medical evidence supports Botox therapy in this clinical setting.  Botox is an established treatment for chronic migraine, which is a disabling condition.  In sum, this patients condition is refractory to other preventive medications, and she has responded to Botox therapy.  All told, Botox injections from the date in question forward were and are medically indicated for the treatment of this patient.