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

This patient is a 28-year-old female who has a history of neck, shoulder and back pain apparently related to an injury three years ago. She also experiences headaches and stress and anxiety possibly related to the injury. Furthermore, the patient has complaints of pre-menstrual syndrome and menstrual symptoms. It is also noted from the submitted records that the patient experiences digestive problems, e.g., bloating after eating. It appears from the records provided that she is taking prescribed medications for the anxiety and stress symptoms. The patient began acupuncture treatments in May 2005 and has had treatment up to and including August 2005. The patient feels her symptoms have improved since she began to receive acupuncture treatments.At issue is whether acupuncture is medically necessary for treatment of the patients condition.Acupuncture is beneficial in pain cases, whether the pain is myofascial in nature, results from sprain/strain injuries, or is secondary to menstrual cramping/dysmenorrhea. The patient was treated with acupuncture from May through August 2005. The submitted acupuncture notes indicate that there has been improvement in the patients presenting complaints and that based on the improvement, the plan is for the patient to be able to reduce the frequency of treatment. The acupuncture treatment rendered has been appropriate and has been of some benefit to the patient. As such, continued therapy (8 to 10 treatments) at a decreasing frequency is medically reasonable and appropriate for this patient. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested positron emission tomography/computed tomography (PET/CT) fusion for medical evaluation of her nodular sclerosing Hodgkin disease.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other methods of evaluation.  The Centers for Medicare and Medicaid Services decision memo recognizes the utility of PET/CT in the diagnosis, staging and surveillance of therapy for all solid tumors, including lymphoma.  The memo approves up to three scans for all solid tumors.  PET/CT has the unique ability to offer physiologic analysis of tumors.  This feature is not available with other conventional imaging techniques.  All told, the superior efficacy of PET/CT has been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee requested psychiatric residential treatment center level of care services for medical treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found thatthe medical records do not support the medical necessity of psychiatric residential treatment center level of care according to the criteria as outlined by the American Academy of Child and Adolescent Psychiatry (AACAP). There are no records included for review that support that the patients condition failed to respond to intensive outpatient program (IOP) or partial hospitalization program (PHP) level of care treatment. The records indicated that the patient had two prior admissions, but it is unclear whether these were in a residential treatment center, hospital, or crisis stabilization unit, and whether the patient received any type of ongoing treatment following discharge. Based on records reviewed, the patient appeared to be stable enough to be transferred to a lower level of care. In addition, Joshi and Rosenberg noted that children who demonstrate conduct type symptoms seemed to do most poorly in residential treatment setting. All told,  psychiatric residential treatment center level of care services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested surgery to re-innervate the abdominal wall musculature for the treatment of her chronic left flank pain and bulging, status post left 12th rib resection. Findings:  The physician reviewer found that several evaluations by in-network surgeons did not find any apparent anatomic problem (i.e., a hernia). It was suspected that a nerve injury had occurred from the rib resection or subsequent hernia repair, resulting in denervation of the muscle with atrophy. While the patient has a contour deformity, it does not appear that the condition sustained as a result of the rib resection has resulted in a significant functional impairment that is not amenable to conservative management. This case does not qualify as reconstructive surgery since the condition does not rise to the level of an abnormal structure of the body.  While there is a slight irregularity, surgical correction will not result in more than a minimal improvement in the patients appearance, and is therefore cosmetic rather than reconstructive in nature. While the patient reports experiencing some residual pain, there is no documentation of a trial of gabapentin, lidoderm patch, and Botox or steroid local injections into the scar as proposed by the Plan. The recommendations of the in-plan physicians for conservative management are medically appropriate. Surgical intervention is only indicated for patients that have failed optimal medical management.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested for Focalin XR 25mg for treatment of her attention deficit disorder. Findings:  The physician reviewer found that the clinical trials that led to FDA approval for this compound did include a proportion of subjects who were given more than the 20mg per day dose. While the subjects who received 30 or 40mg per day did not demonstrate increased efficacy over those who received 20mg per day, the higher dose groups did experience a higher frequency of several side effects. There appears to be little benefit in providing doses beyond 20mg per day, and there is increased risk. The provider does not provide any basis for the statement that the patient quickly metabolized the drug.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested proton beam therapy for the treatment of prostate cancer.Findings:  The physician reviewer found that given the small volume of tumor, conventional radiation therapy is likely to be effective. Both IMRT and proton beam radiation are equally effective. Proton beam therapy has no clinical or physical superiority over IMRT.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for two one-hour speech therapy sessions per week consisting of oral motor intervention using Beckman Oral Motor techniques. Williams syndrome is caused by a deletion of part of chromosome 7. children with Williams syndrome to have a unique cognitive and behavioral profile. The authors noted that, Children demonstrate a relative strength in language and verbal short-term memory, with a significant weakness in visuospatial construction.  the core difficulties associated with Williams syndrome have a cascading effect on many areas of development over time. Thus, speech therapy is medically necessary for this patient to address her impaired pragmatic language, and low tone and muscle weakness. The records document that the patients provider has utilized an approach referred to as the Beckman Oral Motor Protocol. Although there is limited peer-reviewed medical literature available specifically addressing Beckman Protocol, this is only part of the speech therapy that is being provided by the patients provider. The patient meets the criteria for oral motor therapy, and Beckman Protocol is one form of this therapy. Given the patients progress with this providers treatment regimen, the Beckman Protocol and therapy focusing on pragmatic speech as provided by the therapist are appropriate for this patient. The requested services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. For these reasons, the requested two one-hour speech therapy sessions per week consisting of oral motor intervention using Beckman Oral Motor techniques are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 neurology with special qualification in child 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

A 51-year-old female enrollee has requested coronary CT angiography (CTA for evaluation of her chest pain.  Findings:  The physician reviewer found that CT angiography is not thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. In this instance coronary artery disease had been excluded based on cardiac catheterization which is a definitive test.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injection. The provider noted that this patient presented with a history of gastroparesis with nausea and vomiting. The provider noted that the patient received a Botox injection for the treatment of his gastroparesis. Injection of Botox has not been demonstrated to be safe and effective for the treatment of gastroparesis in randomized controlled clinical trials. Moreover, the American College of Gastroenterology (ACG) guideline for the management of gastroparesis states that intrapyloric injection of Botox is not recommended for patients with gastroparesis. Given these findings, the Botox injection was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Botox injection was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not 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 internal medicine with subspecialty certification in gastroenterology 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 43-year-old male enrollee has requested azithromycin 250mg, twice per day for the treatment of his Lyme disease. Findings:  The physician reviewer found that the submitted information reveals no clinical or laboratory evidence of any infection. The patient has been treated with several times the recommended duration of antibiotics for Lyme disease. There is no evidence that he has Babesia or Ehrlichia infection based on the results of the single serologies provided. Furthermore, although azithromycin is appropriate therapy for Babesia, the recommended therapy is a maximum of 11 tablets.  Thus, azithromycin 250mg, twice per day, is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for inpatient chronic pain management program. The records provided for review document that this patients chronic migraines have persisted despite medical therapy and supplements for the treatment of migraines. The patient has also been treated with other forms of supportive care such as massage, acupuncture and biofeedback. However, there is no documentation that the patient has exhausted traditional medications for aborting acute migraine and prophylactic medications for the prevention of migraines. Acute treatment consists of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans. Among triptans, sumatriptan nasal spray has been demonstrated to be safe and effective for pediatric patients. Moreover, preventive therapies including propranolol, amitriptyline, levetiracetam, valproate, and topiramate are recommended for use in this clinical setting. All told, the requested inpatient chronic pain management program is 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 neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

The spouse of a male enrollee requested molecular profiling for evaluation of the enrollees acute myeloid leukemia (AML).  Findings:  Two physician reviewers found that the services at issue were likely to be more effective for this patient than other available treatment options. The medical literature supports the services at issue in this clinical setting. The use of molecular markers to enable risk stratification is encouraged by National Comprehensive Cancer Network (NCCN) guidelines. Based on the records provided and medical literature cited, molecular profiling was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested Namenda (memantine HCl) tablets, 10mg for treatment of his cluster headaches. Findings:  Three physician reviewers found that this patient has a headache history consistent with chronic cluster headaches.  Guidelines for preventive treatment of cluster headaches recommend verapamil at a daily dose of at least 240mg (with maximum dose depending on efficacy or tolerability). Methysergide, lithium and topiramate are recommended as alternative treatments.  There is a lack of support for the use of Namenda as prevention for cluster headaches in the medical literature. There is literature showing that various anti-seizure medications, including Depakote and Neurontin, can be beneficial.  Thus, there are a variety of standard therapies more likely to be beneficial for this patient.  In this patients case, the requested medication is not likely to be the most beneficial available treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total abdominal hysterectomy, possible oophorectomy for treatment of the enrollees severe vaginal bleeding. Findings:  The physician reviewer found that in choosing an alternative to hysterectomy, both safety and efficacy need to be considered for each treatment. It must be recognized that alternatives to hysterectomy allow the possibility for new leiomyomas to form, and/or for preexisting small or undetected leiomyomas to exhibit significant growth, necessitating another treatment. The risk of recurrence must be balanced against the potential benefits of uterine sparing procedures.  Contraceptive steroids are often first-line therapy for control of abnormal uterine bleeding and painful menstruation in women with and without leiomyomas. However, evidence-based reviews suggest that current medical therapies tend to give only short-term relief, and the crossover rate to surgical therapies is high.  In this case, the patient has a fibroid uterus and has failed several attempts at medical therapy. In addition, her menometrorrhagia is significant and has required several blood transfusions. The medical evidence supports the requested services in this clinical setting. Final Result: The reviewer determined that the requested services 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 obstetrics and gynecology 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 48-year-old female with problems related to dysfunctional menstrual bleeding since 2001. In addition, she is treated for severe rheumatoid arthritis and diabetes. In January 2006 the patient presented with the complaint of bleeding from December 2005 to the present; over a 5-day period, the bleeding was described as heavy enough to require changing a pad every 30 to 45 minutes. The providers workup included a normal endometrial biopsy, normal thyroid function, and PTT which was pending but also presumed normal. An ultrasound in January 2006 confirmed the presence of several small (less than 2cm) intramural uterine fibroids in addition to a 1cm submucosal fibroid. The patient was given a trial of progestins in an attempt to control her bleeding as she was not a candidate for oral contraceptives due to her history of diabetes.  The hormone therapy was not successful and caused significant side effects. The patient and her provider discussed the surgical options and the patient refused a hysterectomy, stating that the reduced level of activity postoperatively would exacerbate her arthritis and cause her a great deal of pain. Alternatively, her provider proposed a hysteroscopic resection of the submucus fibroid with concurrent endometrial ablation as this is an outpatient procedure with minimal postoperative down time. The patients provider submitted a request for authorization of the hysteroscopic myomectomy and ablation.  The request was denied by the Health Plan on the basis that it was not medically necessary.The patient is an appropriate candidate for hysteroscopic myomectomy of a small submucus fibroid with concomitant endometrial ablation. ACOG endorses the use of hysteroscopic myomectomy and/or ablation as an alternative to hysterectomy. While acknowledging that as many as one third of the women who undergo ablation go on to require hysterectomy, the ACOG guidelines also cite studies that indicate the failure rate increased over time, and only 8.5% of ablated patients required hysterectomy within a three-year period. The patient will presumably enter menopause within three to five years and does not require permanent amelioration. A submucosal myomectomy will increase the likelihood of successful reduction in bleeding. In one large study, women who underwent both ablation and hysteroscopic submucosal myomectomy had only an 8% chance of undergoing a second surgery within a six-year period. The patients concerns with regard to her rheumatoid arthritis along with her diabetes combine to make her a rather poor surgical candidate; ablation with hysteroscopic myomectomy presents fewer surgical risks than hysterectomy. Finally, ACOG Guidelines for Quality Assurance require that there be no remedial endometrial pathology (e.g. submucus fibroid) before a hysterectomy is considered for abnormal uterine bleeding in premenopausal women.Based upon the information set forth above, I have determined the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for three-to-five 20-minute speech therapy sessions per week. Researchers state that childhood apraxia of speech (CAS) affects a child's ability to produce sounds and syllables precisely and consistently, and to produce words and sentences with accuracy and correct speech rhythm. They state that it is a rare condition, affecting only 0.1% of the general population. A deficit in motor programming or planning is thought to underlie the condition. The American Speech-Language-Hearing Associations clinical topic on childhood apraxia of speech states that a high treatment dosage for CAS is consistent with principles of motor learning. The clinical topic states that for younger children, the frequency and length of sessions may need to be adjusted (e.g., shorter, more frequent sessions are often recommended). In this case, the patient has severe childhood apraxia of speech, resulting in severe expressive language delay. This discrepancy is likely to lead to frustration and impair the patients social interaction with adults and her peers. Under these circumstances, intensive speech therapy is necessary and appropriate as well as consistent with American Speech-Language-Hearing Association guidance. Accordingly, four 20-minute speech therapy sessions per week are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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.