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

The parent of a 20-month-old male has requested speech therapy for treatment of his autism.  Findings:  The physician reviewer found that the available peer reviewed medical literature indicates that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested authorization and coverage for a custom fabricated knee brace with open hinges for treatment of the enrollees left anterior cruciate ligament (ACL) tear.  Findings:  The physician reviewer found that the documentation submitted for review indicates the patient has a long-standing history of a complete ACL tear that has been previously treated with a standard knee brace and physical therapy. The patient indicates she needs a new brace as the old brace is now loose-fitting. However, the clinical notes submitted for review fail to demonstrate that the patient requires a custom-fabricated brace versus a pre-fabricated brace. Strutzenberger and colleagues stated, [s]leeve braces might not be needed in simple daily life tasks, but could provide beneficial support in more dynamic settings like sport and physical rehabilitation training. Another study found that although enhanced proprioception may be somewhat responsible for reported improvements with the use of a brace, the changes observed were small and the functional significance is questionable (Birmingham, et al.). Given the information available in the peer reviewed medical literature and the provided clinical documentation, the requested custom knee brace is not medically necessary and the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for skilled nursing facility services. Chronic leg wounds in the setting of venous stasis can be difficult to heal, with many wounds persisting beyond 6 months. The cornerstones of care include compression and keeping wound beds moist to promote autolytic debridement, angiogenesis and formation of granulation tissue. The records in this case indicate that the patient had chronic edema, venous stasis, and a traumatic right knee area wound which was very slow to heal. As of late October, she was receiving a wound treatment regimen which consisted of a wound VAC dressing being changed on an intermittent basis. The records do not indicate that the patient required any treatments that could not have been provided in the community setting. Her functional status otherwise remained essentially dependent for mobility and lower body self-care, in part due to her ongoing non-weightbearing restrictions for the right lower limb. Ongoing skilled nursing facility level care on the dates of service at issue would not have been expected to marginally improve her clinical course or outcomes over community-based care. The records do not otherwise document services that the patient needed in an inpatient setting that could not otherwise have been delivered in the community with custodial level assistance and home nursing and therapy services.Final Result: The reviewer determined that the skilled nursing facility services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested  for high intensity focused ultrasound (HIFU) for treatment of his prostate cancer.   Findings:  Three physician reviewers found that studies show short-term results measuring 1-2 years at the most, which is inadequate to determine the safety and efficacy of the procedure as treatment for prostate cancer. There are standard therapies in this setting that are supported by peer-reviewed, long-term data. Such therapies are more appropriate for this patient than HIFU, the benefit of which remains speculative at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation supports the necessity of the patients residential treatment center stay. The patient has a long history of alcohol use disorder with a recent relapse noted as a four-day drinking binge, which resulted in a visit to the emergency room. The patient was admitted for detoxification and withdrawal management services, and they subsequently started treatment at a residential treatment center. On the day prior to the period in issue, the patients Addiction Severity Index-Lite (ASI-Lite) Summary noted that the patient discussed having a plan to commit suicide and had made two attempts in the past. On the last day of the period in issue, the patients discharge summary noted that the patient reported passive suicidal ideation without an active plan. The patient denied any acute suicidal ideations and was deemed stable for discharge and was negative for alcohol withdrawal symptoms. The residential treatment center stay during the period in issue was medically necessary for the stabilization of the patients psychiatric symptoms, including their recent relapse of alcohol use, which could have been life threatening. Accordingly, all of the residential treatment center services provided during the period in issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services in issue were medically necessary for treatment of the patients medical condition. Therefore, the patient should be reimbursed for the services in issue, and the Health Plans denial should be 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin pen injector. The patients height is not more than two standard deviations below the mean for age and gender. In addition, no evidence was provided of height fall-off. Results of laboratory testing ruling out other causes of short stature were not provided for review. Information on the patients insulin like growth factor-1 (IGF-1) and insulin like growth factor binding protein-3 (IGFBP-3) levels are not provided. The patients bone age is normal for his age. Applying the American Association of Clinical Endocrinologists and Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee guidelines, the patient does not meet standard criteria for GH deficiency. Thus, the requested Nutropin AQ Nuspin pen injector 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient treatment and weekly talk therapy for treatment of her behavioral health condition. Findings:  The physician reviewer found that The requested services are not medically necessary for treatment of the patients medical condition. In this case, inpatient treatment is not medically necessary for treatment of the patients medical condition. The medical records do not support inpatient level of care services. She has recently started an IOP program and has attended less than 10 sessions of this program. She appears to have some emerging engagement with her treatment providers. Continued treatment in this program is medically reasonable and appropriate for this patient. The medical literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for treatment of anorexia nervosa. Without a specific medical complications or need for refeeding, inpatient admission is typically not recommended for treatment of anorexia nervosa (Hay, et al). Moreover, the request for weekly talk therapy is not a specific type of treatment. Based on the documentation submitted for review, the patient is receiving several hours of individual and group psychotherapy weekly through her IOP which is medically adequate. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the gene test provided. Findings:  The physician reviewer found that when fine needle aspiration (FNA) cytopathology is indeterminate, repeat FNA and or thyroid surgery were the standard options to obtain a definitive pathological diagnosis. Afirma gene expression classifier can help to identify benign thyroid nodules in patients with indeterminate FNA cytology . In this particular case, when the patients initial FNA cytology came back as benign, FNA could have been repeated, and if cytology was still indeterminate, surgical resection should have been considered. All told, the gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1,2 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested total ankle replacement for the treatment of her left ankle post-traumatic arthritis. Findings:  Three physician reviewers found that patients are often mistaken and believe that ankle replacement surgery will allow them to resume an unrestricted lifestyle. In addition, ongoing conservative care with lightweight bracing, intermittent injections, anti-inflammatory medications, shoe wear modification, and activity modification often give patients significant improvement in their symptoms allowing them to do a large number of activities. Ankle replacement surgery is not a proven procedure with a good long-term outcome, and is not likely to be more beneficial for treatment of this patients medical condition than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female who had chronic breathing problems due to a nasal septal deviation. She underwent septoplasty in August 2005, which was done entirely through an internal nasal incision. Following surgery, her provider noted nasal breathing good.  Also interested in cosmetic nasal tip surgery. The patient was advised to wait at least six months prior to any rhinoplasty. The patient now contends there is a nose bump located on the right side of her nose that was not present prior to surgery. She would like this bump surgically corrected.  In March 2006 her provider noted slightly prominent right nasal bone but no external deviation and no saddle deformity. The enrollees request for reconstructive surgery was denied by the Health Plan based upon a determination that a corrective procedure is not medically necessary.A nasal bump is not distinguishable in the provided photographs.  The medical record indicates there were no complications from the surgery and that no external incisions were made. Assuming there is a bump, it is not causing any functional deficits. As such, removing the bump or reshaping that area would only change the patients appearance and would not alter the function of her breathing. The American Medical Association defines cosmetic surgery as surgery that is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem.  The ASPRS position paper agrees, stating that when nasal surgery is performed solely to improve a patients appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedures should be considered cosmetic in nature.  There is no medical indication for surgical reconstruction and the procedure requested by the patient is cosmetic.  Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET). The health plan denied this request indicating that IDET is considered experimental for treatment of the enrollees chronic neck and back pain.All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee requested genetic testing DYT-1 (CPT code 81400), DYT-11 (CPT 81405), GTP (CPT 81406) and cyclohydrolase (CPT 81479) for evaluation of her suspected spasmodic dysphonia.  Findings:  Two physician reviewers found that the patients history and physical examination document a diagnosis of spasmodic dysphonia that has been successfully treated with Botox. The scientific data demonstrates the superior effectiveness of Botox injections into the laryngeal muscles for spasmodic dysphonia. However, the use of genetic testing to show if the patient is a candidate for deep brain stimulation is not supported. All told, the requested genetic testing consisting of DYT-1 (CPT code 81400), DYT-11 (CPT 81405), GTP (CPT 81406) and cyclohydrolase (CPT 81479), is not likely to result in an improved health outcome in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that as per the medical guidelines, all patients with virologic evidence of chronic HCV infection, except for those with limited life expectancy of less than 12 months due to non-related conditions, should be considered for treatment. Candidacy for treatment is limited mainly by the presence of contraindications to the available regimens. Harvoni is a Class 1, level A recommendation. Therefore based on the guidelines Harvoni is appropriate and medically necessary. 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 with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for right and left occipital nerve block injections and prospective authorization and coverage for future right and left occipital nerve block injections for treatment of the enrollees bilateral occipital neuralgia.  Findings:  The physician reviewer found that The physician reviewer found there is sufficient support for the services at issue in this patients case. There are randomized, prospective, double-blind studies which show the effectiveness of occipital nerve blocks for the treatment of occipital neuralgia and to decrease the frequency of migraine headaches. Further, clinical practice guidelines support the performance of occipital nerve blocks for occipital neuralgia. The medical evidence supports occipital nerve blocks in this clinical setting. Therefore, right and left occipital nerve block injections and future right and left occipital nerve block injections were and are likely to be more effective than other treatment options. Final Result: Two of three reviewers determined that the services at issue were and are 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 number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees major depressive disorder and post-traumatic stress disorder (PTSD).  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings offer optimization of treatment gains. However, due to multiple factors and unique considerations, determination of the appropriate level of care and length of stay for adolescent patients with multiple psychiatric conditions can be a challenging endeavor. Based on this patients longitudinal history, psychiatric comorbidity, symptom complex, family environment, characterological organization and psychosocial factors, a conservative residential stay is to be expected. She has chronic suicidality, depressive symptoms, anxiety and strained relations with father, in addition to poor insight and little investment in her treatment. In reviewing the clinical documentation, the services are reasonably expected to improve the patients condition and prevent a more serious episode of illness. The evaluating team and her treatment providers have recommended residential care. Considering the patients current status, recent behaviors and clinical history, she would likely decompensate in the absence of treatment at the residential level of care. The evidence-based services provided thus far have been for active treatment and have been delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting. The anticipated discharge date will allow the team to determine the best aftercare plan and facilitate a seamless transition to the next treatment setting. For these reasons, the residential treatment center services were and are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer 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 psychiatry with sub-specialty certification in child and adolescent 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