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

The parent of a male enrollee requested occupational therapy (twice per week), speech therapy (twice per week) and 15 hours per week of applied behavior analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that the current medical evidence supports the requested services in this patients case.    In sum, the requested occupational therapy (twice per week), speech therapy (twice per week) and 15 hours per week of applied behavior analysis (ABA) therapy are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Firdapse (amifampridine) tablets three times a day. Congenital myasthenic syndromes are a genotypically and phenotypically heterogeneous group of neuromuscular disorders, which have in common an impaired neuromuscular transmission. There is a lack of standardized treatment protocols or guidelines to manage patients with these conditions. In this case, the patient has congenital myasthenic syndrome with GFPT1 mutation. The patients condition has not improved despite treatment with pyridostigmine. Based on a review of the literature, the addition of amifampridine is appropriate and is likely to be beneficial in congenital myasthenic syndromes and patients with the GFPT1 mutation, as in this patients clinical scenario. For these reasons, the requested Firdapse (amifampridine) tablets three times a day is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Firdapse (amifampridine) tablets three times a day 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 medication 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 overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology and is 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 19-year-old male enrollee has requested rhinoplasty to be performed in conjunction with septoplasty (and turbinate reduction) for the treatment of his chronic nasal obstruction. Findings:  The physician reviewer found that the description of the patients nasal septal deviation as being off of the nasal spine along with a mid-third nasal dorsal deviation strongly suggests that the mid-third dorsal deviation is secondary to the dorsal septal deviation. An open rhinoplastic approach  would facilitate complete correction. It is unlikely there would be an optimal result in terms of the patients nasal airway, with a septoplasty and turbinate reduction done by a simple endo-nasal approach. Septorhinoplasty should be performed as a single procedure for this patient, both to facilitate correction of the nasal airway and to avoid two anesthesias. It is probable that full correction of the septum will correct the dorsal deformity as well and therefore no aspect of the surgery what would be considered cosmetic. If it is determined during the procedure that correction of the septal dorsum does not completely alleviate the nasal dorsal deformity, further correction would be considered cosmetic.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female has requested coverage for past substance abuse residential treatment center (subacute) services for treatment of her alcohol dependence and bipolar disorder.  Findings:  The physician reviewer found that in this particular case, the contemporaneous medical record documentation provided fails to demonstrate the need and application of comprehensive treatment encompassing all elements of the bio-psycho-social model in a 24-hour supervised setting. Further, the submitted facility records demonstrate that the patient posed no imminent danger to self or others, expressed motivation for care, and had not pursued less restrictive interventions such as community programming, intensive outpatient or partial hospitalization, which would have been interventions and consistent with the standard of care in this setting.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for hyaluronan injection (Synvisc) to the left knee. The enrollee has chronic left anterior knee pain and type one complex regional pain syndrome. The enrollee has a history of left knee arthroscopic meniscectomy and chondroplasty. The enrollee reports a previous hyaluronan injection (Synvisc) to the left knee helped significantly. The enrollees physician strongly recommends hyaluronan injection (Synvisc) because of the enrollees osteoarthritis, her inability to take non-steroidal anti-inflammatory drugs, and her strong desire to minimize opioids. The medical records indicate the enrollee has completed conservative treatment without resolution of symptoms.  The use of hyaluronan injection (Synvisc) injection is supported as a conservative option to address knee arthritis.  Studies show hyaluronan injection (Synvisc) is effective for osteoarthritis. It improves both pain and function, while sparing additional use of anti-inflammatory treatment and corticosteroids. A professional society recommends intra-articular hyaluronan injection (Synvisc) for the treatment of osteoarthritis of the knee for adults who do not respond to other treatment options, and a task force of experts support hyaluronan injection (Synvisc) injection for early and advanced cases of osteoarthritis when the individual declines surgical intervention.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 16-year-old female with a several year progressive history of antisocial acting out behavior including running away from home, truancy, periodic substance abuse, and oppositional defiance. The patient was apparently treated as an outpatient for a short time. A trial of Depakote resulted in equivocal results. The patients parents were unable to control the patients behavior and poor peer contacts. She was diagnosed by an outpatient psychiatrist as borderline personality disorder, rule out bipolar disorder, adjustment disorder, and disturbance of emotions and conduct. In August 2002, the patient was admitted to a residential treatment center. The patient has no apparent history of suicidal ideation or behavior or psychosis. A request has been made for reimbursement for residential treatment services received from 8/23/02 to 12/31/02. The Health Plan indicates the submitted clinical information does not support the medical necessity of treatment at the residential level of care.Based upon the submitted records, at the time of the patients admission to the residential treatment center in August 2002 the patient was out of control due to her pathology. In view of the patients condition at that time, the patient was in need of residential treatment services for evaluation and stabilization. Review of the documentation provided demonstrates that the patient required containment, structure, and treatment. However, after thirty days at residential level treatment the patients condition had stabilized and transfer to a partial hospitalization program would have been medically reasonable and appropriate. There is no evidence that as of 9/23/02 the patient posed a threat to herself or others. The patient was cooperative and able to participate in treatment. Thus, as of 9/23/02 the patient could have been appropriately treated in a partial hospitalization program followed by intensive outpatient treatment. Based upon the information set forth above, I have determined that residential treatment services were medically necessary for treatment of the patients medical condition until 9/23/02. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement for inpatient hospital stay. Traisman explains that urinary tract infection (UTI) is a common pediatric infectious disease that occurs throughout all age groups and the age of onset, gender, history, and physical examination results determine treatment and long-term management. Pathogenesis is multifactorial, and may result from dysfunctional voiding, instrumentation, turbulent flow from voiding abnormalities, or hematogenous spread. The most common organism is Escherichia coli (E. coli), although viruses and other bacteria may also be responsible for UTI. Presentation of infection varies by age and degree of infection. In young infants, presentation may include fever, lethargy, irritability, poor feeding, vomiting and diarrhea. An examination may reveal ill appearance, costovertebral angle tenderness, and abdominal tenderness. Urinalysis may reveal pyuria, bacteriuria, nitrites, leukocyte esterase, and hematuria.  Additional laboratory studies should also be considered depending on clinical presentation. For neonates and young infants, hospitalization for treatment with parenteral antibiotics is necessary. Robinson and colleagues note that for infants and young children with first febrile UTI, a renal ultrasound is recommended to identify potential pathology, and a voiding cystourethrography is indicated in second febrile UTI to rule out reflux. In this case, the patient presented with prolonged persistent high fevers, vomiting, and toxic appearance. The patient was diagnosed with UTI with concerns for pyelonephritis and sepsis. Laboratory studies supported presence of severe infection, with significantly elevated white blood cell (WBC) count as well as elevated C-reactive protein (CRP). Following admission, it took several days for the fever curve to resolve to baseline. The patient remained on parenteral antibiotics during the hospital stay and was transitioned to an enteral antibiotic to complete the treatment course. In this case, given the potential for morbidity and complications, and the severity of the symptoms including the initial concerns for sepsis, the services at issue were medically indicated. Therefore, the inpatient hospital stay 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Norco 10/325, one tablet QID prn and MS ER 15 mg, one tablet TID prn. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. Clinical practice guidelines do not support renewing opiate medications in a high-risk patient. The positive urine toxicology for methamphetamine and the history of overdose when taking Percocet indicate that this patient is high-risk. These are also violations of her opiate maintenance agreement. There are alternative pain medications which she has not reportedly trialed yet. The medical evidence does not support the requested medications in this clinical setting. All told, Norco 10/325, one tablet QID prn and MS ER 15 mg, one tablet TID prn are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 29-year-old female with bipolar disorder, type 1 with a history of past hospitalization for frank mania as well as suicidality. The patient was later stabilized on Lamictal and Depakote following failure of Lithium due to excessive weight gain and development of acne. A chart note from her psychiatrist on 10/14/04 indicates that her mood has been somewhat difficult to control and there continues to be much stress in her life that is easily disruptive and can cause some transient mood instability. It appears that regular maintenance psychotherapy has been helpful. Chart notes of the patients psychotherapist document that due to the extent of the patients illness she went from working as a teacher to being without a job. The patient has had to return to living with her mother due to a lack of funds and is finding it difficult to obtain job interviews. Her family has also been noted as quite critical of the patient, not particularly understanding of her illness, and apt to liken her struggle to that of being lazy. This has all added to her level of depression and the focus of psychotherapy has been on how to surmount these sorts of losses and move towards a greater degree of independence.Therapy notes of 9/28/04 note the patient vacillates between a depressed giving up response and a kind of grandiose push for excellence and cite her mood as moderately depressed, highly anxious. A note of 10/19/04 cites the patient feeling herself getting agitated and her mood as mildly depressed and moderately anxious, speech somewhat fragmented. The patient has requested authorization and coverage for continued outpatient psychotherapy. The Health Plan has denied this request indicating that the requested therapy is no longer medically necessary.All told, this patient has had a very severe decline in functioning due to the extent of her illness, as she went from being employed as a teacher to living at home with her mother, unable to find another full-time job with a violence-restraining order against her from her prior work. Documentation from her psychiatrist as well as her therapist point to some stabilization in mood compared to when she was at her worst, but hardly that of genuine euthymia. To the extent that functional recovery from bipolar disorder can be quite protracted, taking place over the course of years rather than months, it can be expected that both therapy and mainstay medication treatment will need to continue. This seems particularly the case in this instance given the acrimonious environment in which the patient currently lives. Review of the medical literature including the articles cited above clearly supports continued psychotherapy for this patient. Discontinuation of therapy should be based on good, functional recovery as determined by the patients treating psychiatrist. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-month-old male enrollee has requested authorization and coverage for individualized physical therapy and individualized occupational therapy for treatment of the enrollees gross motor skills delay. Findings:  The physician reviewer found that individualized occupational therapy is medically necessary in this patients case.  This patient has delays in fine motor skills, visual motor skills, and self-help skills, in part due to asymmetries in trunk and upper extremity strength.  With its focus on developing self-help skills, including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. As such, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available modalities.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for myoelectric upper extremity orthosis (1 unit code HCPCS-L3999 upper limb orthosis and 90 days CPT 99201 outpatient office visits) for treatment of the enrollees left brachial plexus injury. Findings:  The physician reviewers found the myoelectric elbow wrist hand orthosis is of greater functional benefit than conventional treatment. This device can provide rapid functional gains when used by patients with a paralytic upper limb, such as in this case. The proposed device will allow some functional use of the patients left upper limb for assistance with activities of daily living and feeding. The records indicate that there is no expectation of neurological recovery of the brachial plexus. As such, the myoelectric device will allow functional use of an otherwise nonfunctional limb. For the reasons provided, the request for myoelectric upper extremity orthosis (1 unit code HCPCS-L3999 upper limb orthosis and 90 days CPT 99201 outpatient office visits) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested device 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 overturned.Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in physical medicine and rehabilitation and 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 19-year-old male enrollee has requested three allergy shots per week (immunotherapy) for treatment of his severe allergies.  Findings:  The physician reviewer found that allergic rhinitis can have a significant impact on quality of life, particularly if it is chronic and unresponsive to medical intervention. This patient is noted to have had rhinitis for five years that has not responded to appropriate therapy including antihistamines and nasal steroids. Allergy immunotherapy is clinically indicated if medication and avoidance have been tried and is either insufficiently successful or results in undesirable side effects. This patient was referred by his PCP for an allergy evaluation and presumably adjunct use of allergy injections, since his medical interventions (medications) were not providing sufficient relief. The allergy specialist noted that the patient was medically compliant but continuing to have symptoms. Allergy testing using standard methods confirmed allergen sensitivity that is known to be responsive to immunotherapy.Subcutaneous immunotherapy is a desensitization procedure that uses controlled exposure to known allergens to reduce the severity of subsequent allergic reactions. It has been shown to be effective for pollen, mold, grass, tree, animal allergens, cockroach, dust mite and hymenoptera hypersensitivity (Passalacqua, et al.). For allergic rhinitis or conjunctivitis, a systematic review concluded that subcutaneous immunotherapy results in a significant reduction in symptom scores and medication use, and also has a relatively low risk of severe adverse events (Calderon). Thus, allergy immunotherapy has been shown to be effective in this setting. Based upon the patients documented history and test results, he is an appropriate candidate for immunotherapy. However, it is not customary to provide allergy injections at a frequency of three times a week. Allergy shots twice a week is within the standard of care and is medically indicated for this patient. Therefore, I find that two allergy injections per week are medically necessary for this patient.