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

The representative of a 24-year-old male enrollee has requested inpatient mental health facility treatment for the treatment of the enrollees bipolar affective disorder, manic with psychotic features. Findings:  The physician reviewer found that while the patient may have experienced elements of psychosis associated with drug use in the past, there was no suggestion that he was psychotic, suicidal, homicidal, overly aggressive or regressed and unable to care for himself at the time of admission. There was no mental status examination reported. The patients need for residential treatment was not clearly documented at the time of admission, nor was it documented at any other time throughout the admission. While it was stated that medications were not needed, there was very little description of the treatments given. Based on the information provided, the patient did not require 24/7 professional observation and care. This patients treatment needs could have been safely and effectively provided at a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for three Supartz injections in the left knee (Codes 20610 and J7321). The patient has tried and failed other conservative treatments with the alternative being surgery, which may not be effective. The patients chronic left knee pain due to chondromalacia of patella involving the medial face is Grade 3. This is associated with relatively severe symptoms, including pain, catching, locking, and difficulty with weight bearing. The patient has been treated with non-steroidal anti-inflammatory drugs (NSAIDs), opioids, physical therapy, and corticosteroid injection without significant relief. Given these findings, the requested three Supartz injections in the left knee (Codes 20610 and J7321) 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 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:  An enrollee has requested a 12-week course of Sovaldi for treatment of her hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  There is sufficient support for the requested medication in this clinical setting.  All told, the requested 12-week course of Sovaldi is medically indicated for the treatment of this patient. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for full body magnetic resonance imaging (MRI) for evaluation of the enrollees systematic sclerosis. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for full body MRI. The medical records submitted for review do not demonstrate progression of symptoms or concern for new abnormality. The patient has had negative chest x-rays, negative CT scans of the chest and pelvis, and negative MRI of brain. Further, there is a lack of medical literature available that supports full body MRI in this clinical setting. All told, the requested full body MRI is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, the medical necessity of speech therapy for the treatment of this patient with developmental delay has been established in this case. As noted in the clinical studies and relevant medical publications, a laryngeal or oropharyngeal anatomical abnormality is not required for abnormal language development as seen in young patients with speech and language delays. As the plasticity in the developing brain exists despite the underlying neurologic disease it 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 healthy neural circuitry to overcome delays in speech as well as deficits in communication. In one review article Law and colleagues concluded that, The review shows that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Given that this patient has made progress but continues to exhibit delays, the requested speech therapy should be provided at the current frequency of one hour per week. The patient should be re-evaluated at six months to assess her progress and need for additional services.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old male has requested continued inpatient hospitalization at a non-Plan facility for treatment of epidural abscess.  Findings:  The physician reviewer found that there is no clear evidence that the patients condition was truly stable or that adequate plans had been made for his outpatient care. Transfer was not reasonable at this juncture, as continuity of care and the seriousness of this infection required consistent attention to these and other important issues.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections in both axilla every three months. The authors reported that, Antiperspirants are regarded as the first-line therapy for primary focal hyperhidrosis and can provide significant benefit. Additionally, the authors endorsed Botox injections as a safe and effective treatment option for focal hyperhidrosis. This patient presents with severe axillary hyperhidrosis that has failed to improve with conservative treatment including first-line antiperspirants. Treatment with Botox dosed every six months has been beneficial. However, the patients provider documented complaints of recurrence of symptoms in the interim between injections. In this clinical setting, an increase in frequency to every three months is appropriate and consistent with the peer-reviewed medical literature recommendations. Therefore, the requested Botox injections in both axilla every three months are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Botox injections in both axilla every three months are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue. Based on the records, a transition from the IOP level of care to the outpatient venue would have been safe and clinically appropriate. Although the patient expressed conviction to handle her pain without opioid medication in mid-October, it does not appear as if she had not consolidated the treatment gains necessary to succeed in the outpatient venue, and service delivery in a less restrictive setting would have been inadequate at that time. However, with continued milieu, medication, group and individual therapies, the patient made steady improvement in the weeks thereafter.  For example, she was noted to have improved ego strength and an enhanced locus of control. She was enjoying her poetry and developing more specific educational plans with a goal of obtaining a masters degree in social work.  She was making clinical progress. She was taking driving lessons and was more hopeful for the future. Her insight was improving. The patients mother attended a session and recognized her need for treatment and was agreeable to making changes to help her daughter.  The patient had a solid therapeutic foundation and was active in her treatment while there was no evidence that she had previously failed coordinated outpatient services. She was stable on psychotropic medications. She was not suicidal, homicidal or psychotic. She was not using opiates or experiencing a protracted withdrawal syndrome. She had a supportive family willing to engage treatment services. All told, IOP services were medically necessary from but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

The parent of a three-year-old male has requested  speech therapy for treatment of his autism. Findings:  The physician reviewer found that patients with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech and chronologic age, lack of typical prerequisite sills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). A controlled study comparing autistic children who did and did not receive speech therapy demonstrated that those who did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy and that age, either early or late in life, is not a barrier to speech therapy.All told, there is ample literature supporting speech therapy for this autistic patient with significant expressive and receptive language delays.
Appeal type: Medical Necessity
Decision: Overturned

A 70-year-old female enrollee has requested the medication Benicar (20 mg in the a.m. and 20 mg in the p.m) for treatment of her hypertension. Findings:  The physician reviewer found that the use of a total daily dose of Benicar (olmesartan) 40 mg is medically necessary for this patients clinical situation. In head-to-head studies, Benicar delivered superior blood pressure reduction when compared with other angiotensin-II receptor antagonists at their recommended doses. According to the manufacturer, the dosage of Benicar must be individualized with an initial starting dose of 20 mg. For patients requiring further reduction in blood pressure after two weeks of therapy, the dosage may be increased to the maximum effective dose of 40 mg. A Benicar regimen effectively lowers blood pressure in the elderly patient population. According to the manufacturer, no initial dosage (20 mg) adjustment is recommended for elderly patients due to a concern with modest accumulation in some patients. This admonition is based on the age of a patient, which is one of the criteria used to estimate kidney function in patients, and thus their susceptibility to accumulation. However, a maximum dose of 40 mg is not necessarily contraindicated based on the patients age alone. According to this patients blood test, she has neither hyperkalemia associated with a low glomerular filtration rate (GFR) nor pre-renal azotemia, both of which are contraindications to using Benicar. All told, a total daily dose of 40 mg of Benicar has been effective in controlling this patients hypertension, and there is no evidence this dose is contraindicated based on the information provided.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female is seeking reimbursement for a liposuction procedure for treatment of lipomas of the arms.  Findings:  The physician reviewer found that there are no photographs to support the patients complaints. Nor, has a pathology report been submitted to support the patients complaints. There are no radiologic studies documenting soft tissue tumors. There is no mention of cancer concerns, rapid growth of lesions with pain, or any other symptoms that would arouse tumor concerns. Furthermore, there is no evidence of a fine needle or core biopsy for diagnosis of a medical condition requiring treatment. All told, there is inadequate data to establish that the procedure at issue was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested  for Nutropin AQ injections for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that there is no evidence of growth hormone deficiency as the patient has not undergone growth hormone stimulation testing. In the absence of any evidence of growth hormone deficiency, the medical necessity of growth hormone therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old female, who sought treatment for a severe rash around her eyes with reported pain, swelling, and visual disturbance of several months duration.  Her provider noted dry skin around the eyes and a possible contact dermatitis.  He also noted the patient was unwilling to discontinue cosmetics. The patients provider indicated that contact testing might be appropriate, but did not pursue it. He utilized a radio-allergo-sorbent-test (RAST) to specifically identify the patients IgE response to inhalants, drugs and foods in order to determine if she was allergic. A local steroid was prescribed and the patient was advised against cosmetics.  The RAST panel was negative and there is no additional follow up included in the record.  The patient has requested reimbursement for the cost of the diagnostic services.  The Health Plan denied her request based on a determination that the diagnostic services were not medically necessary for evaluation of her skin condition.The history and physical exam of the patient is not consistent with contact sensitivity.  If the patients provider wished to investigate an allergic response, a total IgE level would have been appropriate.  If positive, it would then be reasonable to pursue more extensive IgE testing for inhalant allergy, but not food or drug allergy. It is not the standard of care to order comprehensive IgE testing without first conducting 72-hour contact testing for a standard battery of contactants and the specific suspect contactants. Therefore, I have determined the diagnostic services at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested bilateral secondary mastopexy for the treatment of her congenital breast asymmetry. Findings:  The physician reviewer found that the clinical documentation provided shows that the extent of the patients asymmetry does not rise to the level that it constitutes an abnormal structure of the body; therefore, the proposed surgery is not considered reconstructive in nature. With regard to whether the surgery is indicated based on general concepts of medical necessity, there is no evidence that the patients condition results in a functional impairment. Furthermore, the submitted records and photographs do not demonstrate breast pathology that would cause significant pain or discomfort. As such, the proposed surgical intervention is not necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested neuromuscular junction testing for evaluation of his chronic bilateral heel pain. Findings:  The physician reviewer found that standard ultrasound or magnetic resonance imaging (MRI) scan can document chronic inflammation of the proximal plantar fascia that can predispose the lateral plantar nerve to entrapment. There is no evidence that neuromuscular junction testing is more appropriate than these diagnostic modalities. In fact, review of the medical literature reveals no peer reviewed outcome data from large scale, randomized, controlled studies supporting the diagnostic value of neuromuscular junction testing in this setting. At this time, there is inadequate evidence demonstrating that the proposed testing will influence therapy or result in an improved outcome in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition.  Three physician reviewers found that the submitted documentation supports the superior efficacy of the services at issue.  The addition of breast tomosynthesis to mammographic screening views has gained worldwide support among radiologists due to the unique tomographic capability of tomosynthesis.  Per the medical evidence, the addition of breast tomosynthesis has been associated with a decrease in callbacks and increased detection of small cancers.  All told, breast tomosynthesis was likely to be of greater benefit than other modalities.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 diagnostic radiology 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

A 22-year-old male enrollee has requested chemical dependency inpatient detoxification and chemical dependency residential treatment for the treatment of his chemical dependency. Findings:  The physician reviewer found that since the patient had no signs/symptoms of detoxification upon admission, there was no need for inpatient detoxification or any treatment requiring a 24-hour environment. The patient could have safely been treated at a lower level of care such as intensive outpatient treatment for chemical dependency. He had no medical or psychiatric co-morbid conditions and presented no risk of harm to self or others necessitating inpatient 24-hour medical supervision and management.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of chest with and without contrast.The submitted documentation does not support that the requested services are medically necessary. Conservative management with NSAIDs, aggressive pulmonary hygiene, early ambulation, and physical therapy remains the mainstay for the management of acute musculoskeletal injuries. In this case, the patient presented with acute chest wall pain after falling in the bathtub. Cross-sectional chest CT imaging is negative for acute osseous, pulmonary parenchymal, pleural, or pulmonary vascular processes. Though chest MRI may be appropriate for the further evaluation of vascular, pleural, space-occupying, and neurological abnormalities within the thorax, there is no documentation to support such indications in the patient at the current time. Under these circumstances, magnetic resonance imaging (MRI) of the chest with contrast is not medically necessary to treat the patients medical condition. In addition, magnetic resonance imaging (MRI) of the chest without contrast is also not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in pulmonary disease and critical care 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.