Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

A 50-year-old female enrollee has requested urgent care services for the treatment of her medical condition.  Findings:  The physician reviewer found that according to California regulations, urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plans service area. The Health Plan defines urgent needed care as any otherwise covered medical service that a reasonable person with average knowledge of health and medicine would seek for treatment of an injury, unexpected illness or complication of an existing condition, including pregnancy to prevent serious deterioration of his or her health, but which does not qualify as Emergency Care. This patient reports that she experienced a flare-up of her rheumatoid arthritis (RA) while outside her Health Plans service area. The notes reviewed from her visit do not support a sudden flare of her symptoms. An acute flare is characterized by the rapid buildup of symptoms over a period of a few days. The providers examination notes indicate minimal swelling with good hand grasp and good strength. Blood tests obtained on that date show a normal hemogram and a normal ESR. Further, the patient had been receiving ongoing treatments for her symptoms prior to leaving her service area. Based on the submitted documentation, there is insufficient data to support a finding that the patient was experiencing a sudden worsening of her arthritis symptoms necessitating urgent care. While intravenous antibiotics may be helpful in controlling symptoms of RA, there is currently no emergent or urgent indication for their use. This patient had been undergoing treatment for her condition and was familiar with the antibiotic regimens. All told, there is no evidence that a reasonable person in these circumstances would believe that her health would seriously deteriorate if she delayed treatment until she returned to the Plans service area.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested coverage for past and future speech therapy at a frequency of two sessions per week, for one hour per session, for ongoing therapyfor treatment of her language delay.  Findings:  The physician reviewer found that this patient has severe developmental delays, cerebral palsy, moderate deafness and severe visual impairments. The records indicate that the speech therapy provided was effective in moving the patient from being non-verbal to a state of speech imitation and the ability to sign. Given this patients complex clinical presentation, she cannot be effectively treated by her parents with a home program. This patient clearly requires continued professional speech therapy intervention. The medical communitys standard of care would be to offer the patient continued individual speech therapy. Children with speech delays can be readily treated (Law, et al.) and even patients with cognitive deficits are candidates for successful speech therapy (Goorhuis-Brower and Kniff). In sum, the speech therapy provided was medically necessary and ongoing speech therapy at a frequency of two hours per week is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male has requested continued occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that occupational therapy is medically indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Volmar and Wiesner and Case-Smith). The research literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of a childs performance to develop intervention strategies when delays are noted. This patient has documented delays in adaptive and fine motor skills and occupational therapy is a medically necessary treatment for such impairments. Occupational therapy has also been recommended for the patients neuro-sensory delays. A systemic review by Polatajko found that no firm conclusions can be made regarding the efficacy of sensory integration occupational therapy techniques due to poor study quality and great variability in interventions and populations. While sensory processing concerns are noted in this patient, evidence-based research supporting a sensory-based occupational therapy program does not exist at this time. As such, although continued occupational therapy is medically necessary to address the patients adaptive and fine motor delays, treatment of neuro-sensory delays should not be included in the patients occupational therapy regimen. An updated occupational therapy evaluation which includes appropriate standardized testing should be obtained in order to measure the patients progress.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 10-year-old female enrollee requested magnetic resonance imaging (MRI) with spectroscopy for medical evaluation of the enrollees thalamic mass.  Findings:  Three physician reviewers found that the differential diagnosis for brain mass in a 10-year-old is broad, including neoplasm or infection.  The medical literature supports the use of MRI with spectroscopy to discern tumor from infection, and low grade tumor from high grade tumor.  Biopsy of deep brain lesions is associated with significant risk of neurologic injury.   Accurate targeting for biopsy increased diagnostic yield and reduces complications.  The requested services may allow avoidance of biopsy, or more accurate targeting if it needs to be pursued.  Thus, the requested MRI with spectroscopy is likely to be superior over other options for evaluating this patient.
Appeal type: Urgent Care
Decision: Upheld

An 18-year-old male enrollee has requested psychiatric services for treatment of his psychiatric condition.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patient was not experiencing a psychiatric emergency medical condition during the period in question. The patient was not an immediate danger to himself or others and he was not unable to utilize, food, shelter, or clothing, due to a mental disorder. According to the medical records provided, the patient did not require detoxification upon admittance to the facility. In addition, there is no evidence of any co-occurring general medical conditions during the disputed period. Furthermore, the submitted clinical records indicate the patient was medically stable during his stay at the treatment facility. Thus, the patient was not experiencing a psychiatric emergency medical condition from the time frame specified.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for Lidocaine 5% patch. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medication in this clinical setting. In the documentation available for review, the patient reports mid-back pain that she is unable to place the Lidocaine gel on. It is unclear how applying a patch to the mid-back would be any easier than applying a gel in the same area. While there is some evidence to indicate that Lidocaine patches help for back pain, Lidocaine gel is equally effective. Also, mid-back pain can be treated with injections and other interventional procedures for pain from arthritic joints. Moreover, the patient reported that pain in the lower back was alleviated with the epidural injection and now the middle back pain is the main focal point of her pain. While the patient reported that multiple treatment options have been tried for her pain, it is not clear that physical therapy has been exhausted specifically for her mid-back pain. Also, the medical literature indicates that behavior therapy is an option for chronic pain and would help avoid medications and injections. Finally, not all medications classes have been optimized or tried for this patients mid-back pain. As such, the medical necessity of Lidocaine patches, as the next best step for this patients pain control in the mid-back, has not been established. For all these reasons, the Lidocaine 5% patch is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for residential treatment center services.The submitted documentation supports that the requested residential treatment center services were, and are, medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. Progress notes document that the patient fulfilled criteria for Dimension 1, as they indicate that the patient displayed moderate withdrawal symptoms, restlessness, irritability, agitation, anxiety and muscle/joint aches as well as post-withdrawal symptoms including hallucinations. For dimension 2, biomedical conditions and complications, the patient has chronic back pain and she is noted to require assistance with mobility, thereby having biomedical problems that require staff attention. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patients major depressive disorder and posttraumatic stress disorder fulfill this dimension. For dimension 4, readiness to change, the patient is noted to blame others and have a defensive attitude. Records reflect that the patient had been in the denial stage but has progressed to pre-contemplation, thereby showing progress but limited readiness to change. For dimension 5, relapse, continued use, or continued problem potential, the patient has a high relapse history and has required more time in treatment to fully develop tools to overcome risk of relapse. For dimension 6, recovery environment, records indicate that the patients recovery environment is filled with people who use alcohol, tobacco, and/or other drugs, and she has not yet identified her triggers well enough. The submitted documentation thereby reflects that the patient has multiple underlying conditions that require effective treatment and that she faces imminent danger if not in a supportive 24-hour treatment setting. Given the severity of the patients illness, residential treatment center services are clinically appropriate for the patient's illness. Accordingly, residential treatment center services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services in issue and requested services were, and are, medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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: A patient has requested authorization and coverage for reduction mammoplasty. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients macromastia and are not reconstructive in nature. This patient has well-documented chronic back and neck pain as well as shoulder grooving. This has significantly impacted the patients daily activities. The patients condition of macromastia is causing functional problems, and the patient is likely to benefit from reduction surgery. In this patients case, the requested reduction mammoplasty is consistent with standard of care. The patient has a functional problem that is directly related to significant macromastia. Breast reduction is a well-known procedure that directly addresses this functional deficit. Therefore, the requested reduction mammoplasty is medically necessary for the treatment of this patient.Based on the records provided, the patients condition constitutes an abnormal structure of the body. The patients photographs show evidence of significant macromastia, resulting in an abnormal enlargement of the breasts. This can be considered a developmental abnormality, as this has increased despite previous breast reduction. The requested services are likely to improve function, as the patient has chronic pain from this condition. Additionally, the requested services are likely to create a normal appearance to the extent possible. Based on the photographs, the requested services are likely to provide more than a minimal improvement in appearance. In sum, the requested reduction mammoplasty is reconstructive in nature.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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transforaminal epidural steroid injections for treatment of the enrollee's chronic low back pain. Findings:  The physician reviewer found that evidence based medical guidelines support the use of epidural steroid injections as a possible option for the treatment of radicular pain defined as pain in dermatomal distribution with corroborative findings of radiculopathy. On the other hand, medical evidence suggests that epidural corticosteroid injections are not effective for spinal stenosis or non-radicular back pain. The criteria for epidural steroid injections include radiculopathy documented by physical examination and corroborated by imaging studies and/or electrodiagnostic studies. Furthermore, patients should have been initially unresponsive to conservative treatment. In this patients case, the records do not support a diagnosis of radicular pain. Instead, this patient has a history of chronic non-radicular low back pain. Physical examination findings did not evidence a focal neurologic deficit. Imaging showed degenerative disc disease at L4/5 and L5/S1 without evidence of a specific nerve root compromise. Prior bilateral L4/5 and L5/S1 epidural steroid injections were provided four times over the prior six months. Her pain relief lasted between two to three weeks. There was no documentation of a functional response or reduction in pain medication. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Given the absence of signs/symptoms or clinical findings of radiculopathy, the use of epidural steroid injections is not supported by evidence based medical guidelines or literature. Additionally, there is no evidence of at least 50 to 70 percent pain relief with multiple prior epidural steroid injections for at least six to eight weeks to support repeated epidural injections. 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 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 authorization and coverage for a special ortho position seat (tomato seat). Based on the available documentation, the requested special ortho position seat (tomato seat), is medically necessary for treatment of the patients medical condition. The patient has developmental delay due to his chromosome disorder as well as hypotonia and hyperlaxity of most joints. He is unable to hold up his head when sitting or crawling for more than a few minutes. Photographs of the patients back show bruising over the spinous processes due to pressure from his current chair. He has a history of aspiration pneumonia and gastroesophageal reflux. In the medical literature, Ryan and colleagues noted that the introduction of adaptive seating devices for young children who need support to sit had a meaningful, positive impact on child and family life. Rigby and colleagues reported that children were more able to engage in self-care and play activities when provided with appropriate seating. Overall, the data suggests that appropriate adaptive seating can significantly improve the quality of life for children with developmental and physical disabilities who are unable to sit without support. Given these findings, the requested special ortho position seat (tomato seat) is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 pediatrics and neurology with special qualification in child 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: Overturned

The parent of an 11-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient has a subnormal growth rate and has failed two growth hormone provocation tests. His ADD medications have been reported to have growth-retarding effects. His clinical and laboratory evidence is consistent with growth hormone deficiency, for which growth hormone therapy is appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections for treatment of his medical condition.   Findings: The physician reviewers found that Orthovisc injections are not medically necessary for treatment of the patients medical condition. There is a lack of support in the evidence based literature supporting the requested services. In addition, there are possible complications, which may jeopardize future total knee arthroplasty. A meta-analysis of the efficacy of visco supplementation performed by Rutjes and colleagues included a total of 89 trials involving 12,667 adults with knee osteoarthritis. The authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. In sum, the request for Orthovisc injections to be utilized in the management of the patients medical condition is not medically necessary given the lack of support in the evidence based literature.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 physician 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 patient is diagnosed with right knee osteoarthritis. The patient has been treated with physical therapy, a corticosteroid injection, bracing, and anti-inflammatory medications that failed to relieve her pain. A physical examination revealed medial joint line tenderness and patellofemoral crepitus. An MRI revealed cartilage loss at the apex of the patella and chondromalacia of the medial compartment. The patient was treated with a Synvisc-One injection (CPT J7325) to the right knee. At issue is whether the Synvisc-One injection (CPT J7325) to the right knee was medically necessary for the treatment of this patient. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has been treated with conservative options including physical therapy, a corticosteroid injection, bracing and anti-inflammatory medications. Therefore, the Synvisc-One injection (CPT J7325) to the right knee was medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested service 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 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.