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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injection for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. While Botox has been demonstrated to have efficacy in treating chronic headache and chronic migraine in double-blinded studies, it is not considered an initial platform therapy.  Botox is not more likely to improve this patients headache activity as compared to standard treatments including, but not limited to, beta blockers, tricyclic antidepressants, anticonvulsants or serotonin-norepinephrine reuptake inhibitor (SNRI) class of medications.  Therefore, the requested Botox injection is not medically necessary for the 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 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 68-year-old female enrollee has requested Lexapro 10mg for treatment of her depression.  Findings:  The physician reviewer found that this patient has a history of depression.  She reports a failure of two medications in the past as well as intolerable side effects from another medication.  The combination of one of the failed medications and Lexapro has improved her depressive symptoms.  Her Health Plan requires that she fail two one-month trials of SSRI medications, one of them being Celexa, prior to a trial of Lexapro.  This patient has not had even one failure of a pure SSRI medication reported in the past.  Regarding the efficacy of Lexapro, there are clinical trials that suggest that Lexapro may have a faster onset of antidepressant efficacy and modest superiority in the treatment of the severely depressed.  This data shows the possibility that Lexapro can be advantageous to the severely depressed, a category in which this patient does not fit.  In this patients case, the submitted documentation does not establish the medical necessity of Lexapro.  This patient does not have the severity of illness that may benefit from an initial trial of Lexapro, and she has not failed any pure SSRI medication.  All told, Lexapro 10mg is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for six (6) months of RTC services to treat the patients major depressive disorder with psychotic features, substance abuse, and autism spectrum disorder. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm, due to repeated suicidality, substance use, anger and threats at home, and aggression during his most recent RTC admission. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment, due to serious deterioration of interpersonal interactions with consistent conflict with his parents at home and in interactions with peers and staff at the RTC when he was asked to leave group because of his behaviors. With regard to comorbidity, the records support a score of 5. The patient had severe comorbidity, due to the presence of mood disorder, autism spectrum disorder, and significant substance abuse. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to multiple moves between home and various treatment settings, as well as significant difficulties in school. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents active participation in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment. He had persistent symptoms despite an extensive treatment history at various levels of care, including RTC services and multiple psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement, minimizing or rationalizing distressing behaviors and consequences, and glorifying drug use. Thus, the patient has a total score of 26. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the RTC level of care requested. Therefore, six (6) months of RTC services to treat the patients major depressive disorder with psychotic features, substance abuse, and autism spectrum disorder are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 4-year-old male enrollee has requested individual speech therapy for treatment of the enrollees autism and speech delay. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. In this case, the patient has a significant language dysfunction. According to the medical records, by the age indicated, he had been identified as having a moderate delay in expressive and pragmatic (social) speech and his most recent progress note reported a severe impairment of the motor production of speech, also known as childhood apraxia of speech (CAS). There is a large body of literature supporting the value of speech therapy both for delays in expressive and pragmatic speech and for CAS. Lewis and colleagues studied differences in speech/language between children with suspected CAS and children with other speech-sound disorders at school age. The study included children who were diagnosed with CAS at age 4 and reassessed at age 10. At age 10, their improvement was limited compared to children with other speech disorders. The authors recommendation was for intensive speech therapy at age 4. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee requested  magnetic resonance imaging (MRI) with contrast of the breasts for medical evaluation of her breast pain and left breast axillary mass.  Findings:  Three physician reviewers found that based on the available peer-reviewed medical literature and this patients records, the requested breast MRI is not likely to provide additional helpful information relevant to this patients evaluation and treatment. There is no indication for the requested diagnostic procedure given the negative findings on breast mammogram and ultrasound. Further, there is a lack of scientific evidence supporting the clinical utility of breast MRI in this setting. All told, the requested bilateral breast MRI with contrast is not likely to be more beneficial for evaluation of the patients breast pain than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injection for treatment of the enrollees right foot dystonia. Findings: Two of the three physician reviewers found that Botox is considered standard of care for focal dystonia including dystonia of the foot. Undertreated focal foot dystonia can place the patient at undue risk of fall, trauma, and further impairment. In this particular case, the patient has a documented diagnosis of foot dystonia. A trial of Botox would be reasonable for this patients diagnosis. Final Result: The reviewers determined that the requested service 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested for partial hospitalization for the treatment of her eating disorder. Findings:  The physician reviewer found that the patient appears to suffer from a slightly atypical form of regurgitation as part of her bulimia, she nonetheless does suffer from this disorder.  Given the complexity of her problems, attest to her continued struggles with regurgitation and mood irregularities, her course of partial hospitalization was not near completion.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for bilateral lumbar facet injections at L3-4, L4-5, and L5-S1. The enrollee has a history of lumbosacral degenerative disc disease and lumbar spondylosis. She received trigger point injections and a sacroiliac joint injection. She subsequently experienced a severe exacerbation of her back pain and underwent bilateral lumbar facet injections at L3-4, L4-5, and L5-S1. The enrollee reports the bilateral injections are performed each year and she experiences about 11 to 12 months of pain relief from them. A literature review demonstrated no clear differences between various types of lumbar facet injections and placebo interventions. This enrollees pain medication usage has not decreased; even with the lumbar facet injection. Therefore, despite the enrollees report of symptom improvement, clinically, this enrollees pain management did not improve with the lumbar facet injection.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The provider noted a diagnosis of migraine headaches. The provider noted the patient had 16 or more migraine headaches per month, each lasting more than four hours. The patient has requested authorization and coverage for Botox. The Health Plan denied the request and reported that Botox is not medically necessary for the treatment of this patient. At issue in this patients case is whether Botox is medically necessary for the treatment of the patients medical condition. Botox is a validated prophylactic therapy for chronic migraine headaches. The U.S. Food and Drug Administration (FDA) has approved Botox for this condition. Studies show that there is evidence supporting the use of Botox in the prophylaxis of chronic migraines. In this case, the patient has 16 or more migraine headaches per month, each lasting more than four hours. The current medical evidence supports Botox in this clinical setting. Therefore, Botox is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

The enrollee is requesting authorization and coverage for the medication, Tretinoin cream 0.1%. The enrollee has chloasma (melasma). She has been receiving chemotherapy for metastatic breast cancer and the dark patches have worsened since treatment began. The enrollee started Tretinoin cream, 0.05. The provider is now requesting Tretinoin cream, 0.1%. The enrollee indicates she has been coping with this condition for four years. She has dark spots and raised areas on both sides of her face, causing unbearable itching. The enrollee has tried over-the-counter treatments but reports nothing works. Literature describes melasma as a pigmentary disorder with an unclear cause, with numerous treatment options and high recurrence rates. Literature indicates melasma is a problem in the mechanisms that control skin pigmentation. As a result, excess pigment is produced.  The treatment goal is to decrease pigment production and increase elimination. The standard treatment regimen for melasma consists of first-line therapy as a topical treatment with a hydroquinone and a retinoidbased product for a minimum of three months, with the addition of oral tranexamic acid if no contraindication is present. Secondline treatment is noted as laser therapy. Thirdline therapy would be the addition of chemical peels to the above treatments. These examples of first-line, second-line and third-line therapies do not include tretinoin as monotherapy, which is what this enrollee is requesting. Based on the medical literature on topical treatment, the requested treatment is for individuals who acquired this skin condition from UV light and does not account for other correctable factors, such as hypothyroidism or a medication side effect. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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: Upheld

The patient is a 37-year-old female with a history of irritable bowel syndrome (IBS) and constipation. Apparently Zelnorm at the recommended dose of 6mg twice a day was not effective for the patient. The patients provider has prescribed Zelnorm 12mg twice a day. The patient indicates the increased dosage of Zelnorm has been effective. The Health Plan has denied authorization for the requested prescription on the basis that it is not medically indicated for treatment of the patients IBS with constipation.The Food and Drug Administration (FDA) approval for Zelnorm was intended for females with constipation at a dose of 6mg twice daily for a period of four to six weeks with an additional four to six weeks of treatment if necessary. Clearly the proposed doubled dosage is outside the FDA approval and is not the standard of care. There have not been any double-blind prospective studies examining the requested dosage reported in the literature. As such, the safety and efficacy of the proposed dosage is not known and therefore, the requested prescription not medically indicated at this time.Based upon the information set forth above, I have determined that the requested prescription is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested ultraviolet B (UVB) (Dermalight 90 narrowband (NB)-UVB Light) for home use for treatment of his medical condition.  Findings:  Two physician reviewers found that the patient presents with chronic prurigo nodularis of the scalp, which has been complicated with secondary infection in the past. He has had this condition for several years. He has been treated with oral and topical antibiotics, antihistamines and corticosteroids. He has had some relief with the intralesional corticosteroids, but these are not generally considered long-term therapy due to side effects. He also had some relief when he was in a sunny location for a prolonged period. His provider recommends treatment with narrow band-ultraviolet B (NB-UVB). Thus, the patient has requested authorization and coverage for ultraviolet B (UVB) (Dermalight 90 NB-UVB Light) for home use. The Health Plan has denied this request as investigational. Pruritus and prurigo nodularis are very difficult diagnoses to treat, and there is no standard therapy. In fact, there is a lack of drugs approved by the U.S. Food and Drug Administration for use in prurigo nodularis. The standard of care for treatment in this clinical setting has been tried. The use of NB-UVB is a common modality used to treat prurigo nodularis. One advantage to NB-UVB is the low systemic risk. It would be reasonable for this patient who has tried and failed multiple modalities to be treated with NB-UVB. Moreover, other treatments options could pose more systemic risk and would require some monitoring of other organs. Given the above, the requested device has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two 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:  All three reviewers are board certified in dermatology 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: Medical Necessity
Decision: Upheld

The guardian of a 64-year-old female enrollee has requested  inpatient mental health services for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that during the dates of service at issue, the patient was still disorganized and was unable to care for herself or be managed outside an institutional setting. However, there is no evidence of acute suicidality and there is no indication that the provider was directly assessing suicidal risk regularly. Although the patient required an institutional setting during the disputed period, there is no evidence that she was could not have been safely and effectively managed in an intermediate care facility from the date in question forward. Additionally, the treatment involved a non-evidence-based approach of using five different mood stabilizing drugs, with no apparent dose maximization and no consideration of a change to Clozaril despite the fact that the patient continued to be highly symptomatic. As such, the services provided were incompatible with American Psychiatric Association practice guidelines for managing bipolar patients. All told, inpatient mental health services provided from during the time frame were not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested for acute inpatient psychiatric treatment for treatment of her chronic paranoid schizophrenia. Findings:  The physician reviewer found that the patient has a history of suicidality. Thus, a premature discharge prior to patient stabilization would have placed the patient at risk.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 41-year-old female enrollee has requested authorization and coverage for belt lipectomy (CPT 15834). Based on the medical records provided for review, there is insufficient documentation to define a functional deficit related to the patients mild soft tissue excess of the lower back following weight loss. The patient states that she has some functional compromise associated with the lower back excess, but this is not supported by review of the photographs that show a relatively mild condition. The degree of excess skin viewed on the photographs is mild and not the likely source of the patients back pain. Work-up for other causes of the patients pain has not been documented. To satisfy medical necessity, there should be documentation of chronic rashes unresponsive to typical dermatologic treatment or other functional issues unresponsive to conservative management. This is not present in the medical records provided for review. For these reasons, the requested belt lipectomy is not medically necessary for treatment of this patients medical condition. Moreover, there is inadequate evidence of an abnormal structure of the body. The patient has some mild soft tissue excess of the lower back, which does not support the presence of an abnormal structure of the body. The American Society of Plastic Surgeons (ASPS) noted that there can be situations when skin redundancy can cause a functional deficit, such as a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms. However, this patient does not have any documented functional impairment related to the lower back soft tissue excess. Moreover, the requested procedure is not likely to create a more than minimal improvement in the patients appearance based on the photographs. Thus, the requested belt lipectomy is not reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested the BioKnee program for his meniscus and cartilage repair for treatment of his knee pain.  Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been superior over other available treatment options.  This patient has a history of knee pain.  The documentation notes significant arthritis involving the right knee.  At this time, there is a lack of data supporting the long-term efficacy of the services at issue.  There is a lack of data demonstrating that the services at issue were likely to have beneficial in this clinical setting.  All told, the BioKnee program treatment performed on the date indicated was not likely to have been more effective than other treatment options.