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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of residential treatment services, or in the alternative fewer consecutive days of residential treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. In cases such as this, an evidence-based instrument such as the Child and Adolescent Level of Care utilization System (CALOCUS) is indispensable in determining necessary level of care for children and adolescents. In this patients case, she presents with a significant risk of harm (score 4) due to her cutting and passive suicidal ideation. The patients functional status is a serious issue (score 5), as she has had numerous disruptions in her home and school status due to her erratic behaviors including theft. The patient presents with no co-morbid conditions (score 1) with a prior history of substance abuse. The patients recovery environment is highly stressful (score 4) as the progress notes indicate that the patients home life is stressful. The patients recovery environment provides minimal support (score 4) as the patients primary caretakers are reported to have difficulty with emotional support in an inappropriate manner as referenced to by volatile family therapy sessions at the RTC. The patient has demonstrated negligible improvement in prior treatment (score 5) due to extremely minimal positive treatment response in the past at numerous different levels of care. The patients acceptance and engagement in treatment has been adversarial (score 4), as the patient has minimal insight into her treatment needs. The patients parents have been obstructive to treatment (score 3) as they appear to work with providers but have difficulty creating a definition of the problem. Overall, this gives her a composite score of 30, which correlates with a treatment in a hospital or secure RTC. Moreover, the patients presentation suggests risk rating scores in the range of 3. Given these findings, the requested 30 consecutive days of residential treatment services are supported as medically necessary for treatment of this patients behavioral health issues. 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: Overturned

A 64-year-old female enrollee has requested MitraClip for treatment of her mitral valve prolapse.  Findings:  Two physician reviewers found that this patient has clear indications for repair of her mitral valve deformity (Bonow, et al). She has increasingly severe symptoms of congestive heart failure (CHF) and pulmonary congestion given her diuretic therapy, orthopnea, recent onset atrial fibrillation, low normal EF, severe mitral insufficiency on ECHO and catheterization, low forward cardiac output, and thoracocentesis for recurrent pleural effusions secondary to pulmonary congestion. Moreover, due to her low blood pressure and orthostatic symptoms her providers have been unable to add significant vasodilator therapy to her medical regimen, making even medical treatment of the symptoms sub-optimal. Therefore, she meets the American College of Cardiology (ACC) Class I indications for mitral repair. In the absence of definitive repair, she will develop progressive CHF, congestive symptoms, left ventricular dilatation, and increasing cardiac rhythm disturbances based on the known natural history of this disease at this stage. For these reasons, the requested MitraClip procedure is likely to be more beneficial than standard therapies for treatment of this patients medical condition.
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 moderate to severe delays in expressive and receptive language skills. Findings:  The physician reviewer found that Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The current medical literature supports therapeutic intervention for children such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for speech therapy services for treatment of the enrollees misarticulations. Findings:  The physician reviewer found that according to Law and colleagues, approximately 6% of children have speech and language difficulties. These reviewers concluded that this meta-analysis showed a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested orthopedic surgeon for evaluation of the enrollees low back pain.  Findings: The physician reviewer found that this patient presents with a significant flare-up of his chronic low back pain. The patient has reported persistent severe left-sided low back pain radiating into the left leg with numbness. The patient has been evaluated with initial treatment by a physical therapist and a chiropractor without benefit. X-rays demonstrated degenerative disc disease at L2-3, L3-4 and L4-5. The patient was previously diagnosed and treated by an orthopedic surgeon for lumbar degenerative disc disease and radiculopathy with physical therapy, home exercise, and epidural steroid injection with benefit. The American College of Environmental and Occupational Medicine (ACOEM) guidelines recommend non-prescription medication or appropriately selected anti-inflammatory medications, activity modification, and use of heat/cryotherapies for initial treatment. Primary care providers can effectively manage low back problems conservatively. Strengthening and stabilization exercises are not recommended until acute low back pain has subsided. If symptoms persist without improvement, further evaluation is recommended. Given this patients history of chronic low back pain and failure of more than six weeks of self-care methods and initial physical medicine treatment, referral for an orthopedic consult is reasonable. Therefore, the requested referral to an orthopedic surgeon is medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Experimental/Investigational
Decision: Upheld

A 25-year-old male has requested coverage for occipital nerve stimulation (implantable neurostimulator electrode L8680 x 2, electronic analysis of implanted neurostimulator 95972, and percutaneous implantation of neurostimulator 64555 x 2) for treatment of his headaches. Findings:  Two physician reviewers found that the patient has had chronic headaches since childhood. He was diagnosed with cisterna magna/arachnoid cyst at eight years of age. The headaches are localized to the occipital area and spread to the vertex.  The patients pain interferes with his daily life activities. The patient had a shunt placed at the age of 20, with no relief. The medical records noted that the patient had two occipital nerve blocks, with temporary relief for two weeks each time. The patient's list of medication tried include OxyContin, in which detoxification was required due to escalating doses for temporary relief of headaches, gabapentin, Cymbalta, various triptans, benzodiazepines and opioids.  The medical notes indicated that the patient had not tried beta blockers.  He was diagnosed with arachnoid cyst, occipital neuralgia and chronic headaches.  The requested services are not likely to be more effective than other available treatment options. Anticonvulsant medications, antidepressants, beta blockers and triptans are considered in peer-reviewed literature as safe and efficacious therapy for chronic headaches. Occipital neuralgia is the main condition studied in successful trials of occipital nerve stimulation.  Per the submitted medical records, this patient presents with a more complicated picture of headaches than solely occipital neuralgia. There is a paucity of peer-reviewed literature to support occipital nerve stimulation over standard therapy for chronic headaches.  Schwedt and colleagues examined the safety and efficacy of occipital nerve stimulation for medically intractable headache. The study concluded that occipital nerve stimulation might be effective in some patients with intractable headaches.  Surgical revisions, however, may be commonly required.  In addition, safety and efficacy results from prospective, randomized, sham-controlled studies in patients with medically refractory headaches are needed.  Burns and colleagues performed a retrospective assessment of the clinical outcome for 14 chronic cluster headache patients implanted with occipital nerve stimulators in the suboccipital region. They concluded that occipital nerve stimulation provided a safe, effective option for some patients with chronic cluster headaches.  However, the authors noted that more work is required to evaluate and understand occipital nerve stimulation.  Overall, the strength of evidence in the medical literature supporting occipital nerve stimulation for chronic intractable headaches is weak.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested right knee arthroscopy for treatment of his right knee pain.  Findings:  The physician reviewer found that based on review of the available records, it is medically necessary for this patient to undergo the requested right knee arthroscopy for treatment of a meniscal tear as evidenced on MRI. The patients records document the patient initially had a bone contusion. The patients course of treatment was appropriate consisting of strict non weight-bearing with use of a scooter. This treatment for the osteonecrosis was successful as documented in a subsequent MRI. However, follow-up MRI also demonstrated evidence of a meniscal tear. Consistent with current guidelines, the next step in treatment is the requested right knee arthroscopy for management of this patients medical condition. Therefore, the requested service is medically necessary for treatment of the patients right knee pain.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested coverage for past outpatient mental health treatments (at a frequency greater than the authorized one time per week) and coverage for future outpatient mental health treatments at a frequency of two to three times per week for treatment of her multiple mental health conditions.  Findings:  The physician reviewer found that dissociative identity disorder has been described since well before the modern medical era. However, up until 30 years ago, there were few, if any, well-designed, empirical studies of this condition. The increased attention in the literature community the past few decades has led to more cases being discovered of this complicated and controversial diagnosis. Despite its controversy, this condition can be found in the Diagnostic Statistical Manual (DSM). According to Sadock and Sadock and the International Society for the Study of Trauma and Dissociation, psychotherapy is the primary vehicle for recovery in this setting and the most efficacious modality. The treatment team must carefully defend against regression. With the assistance of a multidisciplinary treatment plan that clearly defines boundaries, goals and objectives, it is not uncommon to treat individuals with dissociative identity disorder at the rate of two therapy sessions per week. In keeping with an overarching goal of utilizing the least restrictive treatment setting (American Psychiatric Association), it is medically reasonable and appropriate to treat this condition with two outpatient mental health sessions per week. Accordingly, the treatments at issue were and are medically necessary for treatment of the patients medical condition at a frequency of two times per week.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech therapy for treatment of the enrollees delayed developmental milestones. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient was referred for a comprehensive evaluation because of speech and language delays and behavioral concerns.  Multifactorial assessments failed to yield a diagnosis of autism spectrum disorder, and his speech and language evaluation placed him at the low normal (expressive) to normal (receptive) level of communication for age.  The current medical evidence does not support the requested services in this clinical setting.  Based on appropriate validated testing and clinical observation, the requested speech therapy 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 pediatrics 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 47-year-old male enrollee has requested calprotectin fecal laboratory testing for evaluation of his Crohns disease. Findings:  Two physician reviewers found that the testing at issue was not likely to be more effective than other tools of evaluation.  Per the medical records, this patients symptoms of Crohns disease were under control at the time of testing, and Humira had been initiated.  There is a lack of support for the testing at issue in this clinical setting.  The use of calprotectin fecal laboratory testing would not have been expected to be of benefit in this patients case.  Therefore, calprotectin fecal laboratory testing was not likely to have been of greater benefit than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardiovascular defibrillator (Zoll LifeVest) provided Findings:  The physician reviewer found that The patient is a patient with a history of smoking, obstructive pulmonary disease and diabetes. The patient presented with dyspnea symptoms due to congestive heart failure. The patient was evaluated with severely depressed left ventricular ejection fraction and subsequent cardiac catheterization. The report noted normal coronary arteries without stenosis. The patient was medically managed and discharged  with a wearable defibrillator.  A follow up visit  reported fatigue and exertional dyspnea.  An echocardiogram  later reported a left ventricular ejection fraction of 15%. An implantable defibrillator was placed . The patient requested reimbursement for a wearable cardiovascular defibrillator (Zoll LifeVest) provided . The Health Plan denied reimbursement noting that the device at issue was investigational for the treatment of the patients medical condition.The superior efficacy of the device at issue has not been demonstrated in this clinical setting. In this patients case, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator. The patients record did not demonstrate a 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%) 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.  For example, studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than 35 percent before ventricular function has had a chance to recover have not demonstrated improved outcomes . There is a lack of evidence to demonstrate the superior efficacy of this device over medical therapy, in this patients case. Therefore, according to scientific literature, the wearable cardiovascular defibrillator provided  was not likely to have been more effective than standard treatment options available to this patient.Final Result: The reviewers determined that the device at issue was not likely to have been 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 & 3 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: Upheld

A 23-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that an allergic reaction to a medication is termed a drug eruption. It may occur while a patient is currently taking a medication, or, as in this case, within a week afterward. Some semi-synthetic penicillins may cause drug eruptions even later. Skin manifestations may include uriticaria, erythema, and pruritis. More serious cases may include bronchospasm, laryngeal edema, and shock, producing an anaphylaxis syndrome. This patient was experiencing a drug eruption only. She had no symptoms of anaphylaxis. Drug eruptions are treated by removing the offending agent and prescribing a course of antihistamines such as Benadryl. Steroids may be added as well. This patient had already been adequately treated for her symptoms and was improving. Her symptoms on the date in question were not of a sufficient severity that a prudent layperson would seek immediate medical attention due to fear of jeopardy to his health and/or bodily function.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Provigil for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has fatigue related to multiple sclerosis.  She has been treated with Provigil, with reported benefit.  There is evidence in the medical literature that Provigil can be of benefit in the off-label treatment of fatigue in conditions such as multiple sclerosis.  The alternative treatments have greater side effects and abuse potential.  In this patients case, Provigil is medically indicated.  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 reimbursement for residential treatment center services. The enrollee has a history of bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety, attention deficit disorder, substance abuse, and insulin-dependent diabetes mellitus. He entered a residential treatment center and received individual therapy, group therapy, and medication management. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with Level IV care, a partial hospitalization program.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 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 similar medical condition.