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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an evaluation for an oral appliance and an oral appliance for treatment of his obstructive sleep apnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services and equipment.  In this patients case, he does not have clinically significant obstructive sleep apnea that requires treatment.  If there is concern regarding positional changes of supine sleep, using a vest or shirt with a tennis ball sewed into the garment would prevent supine sleep.  There is no indication for the requested oral device in this clinical setting.  All told, the requested evaluation for an oral appliance and an oral appliance are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services and equipment 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 internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a four-year-old male with a history of speech delay are requesting reimbursement and prospective authorization and coverage of speech therapy.Reviewers Findings:The reviewing physician found that the earlier speech therapy evaluation documents improvement with therapy, no goals or objectives were established to indicate whether the therapy was medically or educationally based.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Review of the patients records demonstrates the patient has multiple medical problems including obesity, congestive heart failure, ischemic disease, hypertension, and angina. The patient also has diabetes with related neuropathy and foot ulcers. The patient currently utilizes a manual wheelchair for in-home mobility, but complains it is becoming more difficult to operate a manual wheelchair. The patient is seeking authorization for a power-operated vehicle (POV).The patients primary care provider believes a POV would be counterproductive, as it would contribute to the patients deconditioning. In addition, a note indicates as of May 2004 the patients upper extremity strength was normal and there is no indication her condition has changed to the point where she can no longer operate a manual wheelchair. Based upon the patients condition, I concur with her provider that a POV would be counterproductive and contribute to deconditioning. Furthermore, there is no clinical evidence demonstrating a POV is medically necessary. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested Daytrana transdermal patch for the treatment of the enrollees attention deficit disorder (ADD). Findings:  The physician reviewer found that the relevant evidence demonstrates that Daytrana transdermal patches are medically necessary for this patient. Adler and colleagues support this finding based on their randomized, double-blind, placebo-controlled, 6-month trial examining the efficacy of the atomoxetine in ameliorating symptoms through the evening hours. Adler and colleagues concluded that in their study of 94 patients randomized to atomoxetine and 112 patients randomized to placebo, the once-daily morning-dosed atomoxetine was efficacious for treating ADHD in adults when measured 10 weeks and 6 months after initiating treatment. Further, Patrick and colleagues state, Concentrations of l-MPH (methylphenidate) typically attain 40-50%...vs. 1-2% following oral MPH and therefore not only address potential swallowing difficulties, but also offers flexible, individualized MPH exposure time in a once-daily regimen. The fact that this patient has shown contraindications to a variety of other oral stimulants and positive response to the requested medication further emphasizes the medical necessity of the Daytrana transdermal patch for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for inpatient rehabilitation including speech therapy, occupational therapy, and physical therapy for treatment of her medical condition status post cerebral infarction without hemorrhagic component.  Findings:  The physician reviewer found that the records indicate that the progress she has made is very likely more related to brain healing than to therapy. The severity of her brain injury makes daily therapy unreasonable as her brain cannot respond to the daily regimen. It is possible her brain will improve and she may be able to gain more from skilled therapy at a later time. However, the patient is not likely to progress with inpatient rehabilitation including speech therapy, occupational therapy, and physical therapy. As such, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Supartz injections for treatment of his medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  In their meta-analysis of 137 studies with 33,243 participants, Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  In this case, the patient has been diagnosed with severe osteoarthritis of the medial compartment of the left knee.  He has undergone two prior viscosupplementation series with positive results documented.  All told, the requested Supartz injections are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees medical condition.  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: The parent of an enrollee has requested coverage for eating disorder intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the requests for eating disorder IOP services are medically necessary for treatment of the patients anorexia nervosa. The documentation submitted for review supports placement at the IOP level of care. The patient continues to exhibit high anxiety at meals and distress when presented with menu options. In this clinical setting, the gains that have been made in IOP are fragile and there is a strong possibility of relapse at a lower level of care. In the absence of IOP services, he would be at risk for medical complications and would likely require a higher level of care. Thus, IOP services are medically necessary for treatment of the patients behavioral health condition.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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zoll Life Vest for three (3) months. Findings:  Three physician reviewers found that the superior efficacy of the device at issue has not been demonstrated in this clinical setting. Based on the records provided, this patient has been diagnosed with a newly recognized nonischemic cardiomyopathy. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. Based on the records, there was no indication for an immediate placement of a defibrillator. The documentation did not indicate sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (greater than 90 days) where continued left ventricular dysfunction (ejection fraction less than or equal to 35 percent) is documented to persist in spite of appropriate treatment. A prophylactic defibrillator, wearable or implantable, before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk, where criteria for implantable defibrillators have not yet been met, are largely comprised of registry data without adequate control groups. Therefore, in this circumstance, a Zoll Life Vest for three (3) months is not likely to be more effective than standard medical therapy available for treatment of this patient. Final Result: 3 of 3 reviewers determined that the requested device is 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested medical services on an emergent basis or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a complex combination of symptoms and exam findings, some of which were chronic and others acute. The acute nature of his findings warranted emergent intervention with EMG, MRI and eventually surgery. Due to the complex nature of his presentation and previous evaluations it was necessary to consult with rheumatology and dermatology to determine an accurate diagnosis. He needed immediate diagnostic testing and treatment to avoid further deterioration and permanent paralysis from cervical cord herniation and compression. The patients health would have been placed in serious jeopardy, serious impairment to bodily function. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services met prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. 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: Urgent Care
Decision: Upheld

A 66-year-old male enrollee has requested for emergency ambulance transportation services at issue were not required on an emergent basis and were not medically necessary. Findings:  The physician reviewer found that the patient was ambulatory at home per the ambulance report, had normal vital signs except for mild hypertension, and had no evidence of cauda equina syndrome. No lab tests were performed and he was treated with intramuscular and intravenous pain medications. The patients pain improved and he was sent home with a prescription for pain and muscle relaxation medications. There is no evidence that the patients symptoms would cause a prudent layperson to believe emergency ambulance transportation was necessary to prevent serious harm or injury.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) (34 sessions). Findings:  The physician reviewer found that  The records provided for review document that this patient has a history of moderate major depression. The provider noted that the patient has not responded to treatment with multiple classes of antidepressants as well as psychotherapy. The patients provider has recommended treatment with TMS for treatment of the patients moderate major depressive disorder. For patients who have not responded to treatment with multiple classes of antidepressants, the chance of achieving remission from pharmacotherapy is low. In the medical literature, multiple studies have reported the safety and efficacy of repetitive TMS therapy for patients with moderate depression non-responsive to pharmacotherapy. Voight and colleagues evaluated six articles were graded high quality demonstrating that the repetitive TMS was clinically efficacious in patients after one medication trial. In addition, the authors noted that four additional trials of lower quality also reported a positive effect with repetitive TMS in patients after one medication trial. Moreover, the U.S. Food and Drug Administration (FDA) has approved repetitive TMS for patients who have not responded to at least one adequate antidepressant trial in the current depressive episode (Cohen, et al.; Somani and Kar). Given these findings, the requested TMS services (34 sessions) 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 psychiatry with subspecialty certification in in preventive 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: Upheld

A 25-year-old male enrollee has requested adult psychiatric acute inpatient services for treatment of his bipolar disorder II, cannabis dependence, alcohol abuse, sexual disorder, not otherwise specified and social anxiety. Findings:  The physician reviewer found that this patients three main issues were alcohol and cannabis abuse, mood symptoms and a sexual disorder. All of these issues were addressed in the treatment setting. A factor of paramount importance in determining the appropriate level of care is the patient's ability to stay sober. This patient was sober for three weeks prior to treatment, indicating success with sobriety outside of a controlled environment. This fact, along with the lack of prior treatment, supports a lower level of care than the services that were provided. In addition, the patient was cooperative throughout his treatment. His mood symptoms were very well-controlled early in his stay. He appeared to have some chronic suicidal ideation without any recent self-injurious behaviors. He did not have any dangerous behaviors in treatment. The patients sexual symptoms did not result in grave disability that would warrant an acute inpatient level of care. An evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is useful in determining the appropriate level of care, to ensure the patients level of care meets his individual needs, safely and effectively, in the least restrictive setting possible. Per these guidelines, adult psychiatric acute inpatient services were not indicated. The American Society of Addiction Medicine criteria for level of placement can also be applied to this patient to help determine the appropriate level of care for his needs.  Per these criteria, based upon his symptoms and functional status, the patient was appropriate for outpatient services or an intensive outpatient program during the period at issue. He could have been treated safely and effectively at a less restrictive setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The transgender male enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding a bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for the evaluation of the enrollees gender dysphoria. Findings: Based on the documentation provided, the patient has gender dysphoria and is transitioning to the male gender. He has lived as a male for many years and has been undergoing prescribed hormonal therapy. The patient binds his chest, which is supportive of a female appearance. He has evidence of female breasts that are considered abnormal for a male. He continues to have gender dysphoria related to breast development. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the goal. The medical documentation is supportive of an initial consultation with a plastic surgeon who is qualified to further evaluate his gender dysphoria and possible role for surgical intervention. Therefore, a consultation regarding a bilateral mastectomy is medically necessary for the evaluation of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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

A 43-year-old female enrollee has requested additional physical therapy sessions for treatment of her back pain. Findings:  The physician reviewer found that this patient has developed an acute worsening of her low back pain associated with restricted movement of her spine. These complaints have required increased narcotic use. The patient has not yet returned to her functional baseline. Additional physical therapy is both clinically appropriate and medically necessary for the management of this patients back pain (Chou and colleagues and Van Tulder and colleagues). Given that the patient has experienced some benefit from prior physical therapy yet continues to have exacerbations of pain, additional physical therapy services are medically reasonable and appropriate in this particular setting. It does not appear that the patient has plateaued and as such there is a reasonable likelihood that she will continue to benefit from physical therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee requested substance abuse intensive outpatient program services for medical treatment of the enrollees alcohol dependence and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support intensive outpatient program level of care in this clinical setting.  This patient was not exhibiting any withdrawal symptoms and displayed mild psychiatric symptoms overall.  Group therapy progress notes indicated that the patient was cooperative in therapy and was open regarding his need for treatment.  Individual progress notes noted that the patient was not experiencing any suicidal or homicidal ideation.  Per American Society of Addiction Medicine Patient Placement Criteria, outpatient services were appropriate for the treatment of this patient.  In this patients case, he could have been treated safely and effectively at a less restrictive setting.  All told, substance abuse intensive outpatient program services were not medically indicated for the treatment of this patient.