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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Stelara 90 mg/mL syringe every six weeks. Dayan and colleagues note that ustekinumab is an effective therapy for Crohn disease currently approved for adults, and while results from 52 children and young adults suggests that ustekinumab is efficacious and safe in pediatric patients with inflammatory bowel disease, controlled clinical trial data are needed to confirm these observations. The authors further reported that while more than 50% of pediatric patients achieved clinical remission on ustekinumab by week 52, higher remission rates were seen in bio-naive patients, with 90% of bio-naive patients in steroid-free remission compared to 50% of bio-exposed patients. Given the relatively limited data on ustekinumab on pediatric patients, a dosing regimen would be extrapolated from adult practice. Battat and colleagues report that maintenance trough concentrations of ustekinumab above 4.5 g/mL at 26 weeks or later are associated with biomarker reduction and endoscopic response. In the case, the patient is on her third dose of ustekinumab. The submitted documentation does not yet provide clear evidence of loss of response to ustekinumab, as fecal calprotectin was noted to be improving. Notes reported some decrease in the patients symptoms, although they have not completely resolved. While the patients ustekinumab level as of 1.5 g/mL was below the goal trough level, the submitted documentation did not include trough levels from week 26, which are not yet available. In this clinical setting, given that current medical literature does not support the use of trough levels before all induction doses have been given, and as the submitted records do not yet document continued low ustekinumab trough at or after week 26, the requested medication regimen is not medically indicated. Therefore, Stelara 90 mg/mL syringe every six weeks is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 pediatrics with sub-specialty certification in pediatric gastroenterology 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 has requested authorization and coverage for consultation with a cardiologist that specializes in adult congenital heart disease. This patient has a congenital ventricular septal defect and a strong family history of severe complex congenital heart disease including a familial hypertrophic cardiomyopathy. Her care has been maintained at a congenital heart disease clinic since she was a child. She has requested to have a consultation with an adult congenital heart disease specialist. The requested consultation is appropriate given her personal history of ventricular septal defect and strong family history of congenital heart disease. Given the patients known history of congenital heart disease, complex family history and familial genetic cardiomyopathy, consultation with an adult congenital heart disease specialist is appropriate. An adult interventional cardiologist is less versed in the care of congenital defects, especially given the complexity and severity of the genetically transmitted familial heart disease involved in this patients family. Given these findings, the requested consultation with a cardiologist that specializes in adult congenital heart disease is medically necessary for this patient.Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested monitored anesthesia care for treatment of her post status colonoscopy. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure. There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  The current medical evidence does not support the services at issue in this clinical setting.  McQuaid and Laine performed a systematic review of randomized controlled trials to compare safety and efficacy of agents used for moderate sedation in colonoscopy or esophagogastroduodenoscopy.  The authors concluded that moderate sedation provides a low risk of serious adverse events.  All told, monitored anesthesia care was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation at the tertiary level of care. Mylotte and colleagues note that clinical guidelines recommend specialized care for patients with adult congenital heart disease (ACHD), and that referral for specialized ACHD care was associated with a significant mortality reduction. The American Heart Association and American College of Cardiology (AHA/ACC) guideline for the management of ACHD  notes the need for specialized care for patients with ACHD. In this case, the patient has complex ACHD. The records document comprehensive congenital care at the tertiary medical center by providers who are specialized congenital heart disease interventionalists. Given the high level of specific experience of the multidisciplinary team dedicated to the ongoing treatment of patients with ACHD, and current medical guidelines recommended specialized care for patients with ACHD, the requested service is medically indicated. Therefore, a consultation at the tertiary level of care is medically necessary for the 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for labiaplasty. The Health Plan has denied this request indicating that the requested surgery was not medically necessary for treatment of the enrollees labial hypertrophy and are not reconstructive in nature. The submitted documentation supports the medical necessity of the requested surgery. The patient complaints include dyspareunia, pain with activity, and pain with wearing clothes. Physical examination revealed asymmetric labia hypertrophy. As noted in the medical literature, there are functional concerns related to labial hypertrophy which can be improved with surgery. Labial hypertrophy is an abnormal enlargement of the labia, which constitutes an abnormal structure of the body. This can be considered a developmental disorder that led to enlargement.  The planned surgery is being performed to improve function and would provide more than a minimal improvement in appearance. All told, the requested labioplasty is supported as medically necessary and reconstructive in nature for treatment of this patients symptomatic labial hypertrophy.Final Result: The reviewer determined that the requested surgical procedure 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 plastic surgery and 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 has requested reimbursement for computed tomographic angiography (CTA). A study found this patients symptoms of syncope and positional vertigo are consistent with problems involving the posterior cerebral circulation. Treatment of this patients presenting symptoms can be conservative or involve revascularization. Imaging studies are required to determine the exact degree and cause of vertebral artery occlusion, as well as which vertebral artery is dominant. In this patients clinical setting, the CTA was indicated given the patients symptoms and their family history of stroke. For these reasons, the CTA was medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has requested acute inpatient services and residential treatment services for treatment of his behavioral health problems. Findings:  The physician reviewer found that acute inpatient treatment during the time period in question was medically necessary. The patient has a well documented history of severe psychiatric impairment with major co-morbidity with diagnoses of polysubstance abuse, schizoaffective disorder and Aspergers syndrome. The patients unstable, psychotic behavior with poor impulse control, paranoia and fluctuating mental status exam warranted the level of care provided. This is consistent with Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) practice guidelines. In regards to residential treatment, it was medically necessary during the time period at issue. Due to severe co-morbidity, including polysubstance abuse, schizoaffective versus bipolar disorder and Aspergers syndrome, the patients overall medical needs were complex and required a specialized multidisciplinary team. Given the patients presentation during this period, the level of care provided was consistent with LOCUS and APA practice guidelines and was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage extraction of 13 teeth with general anesthesia, or in the alternative deep anesthesia. Based on the provided documentation, the patient has asthma, is a smoker, has hepatitis C, and presents with elevated blood pressure during office visits. The planned number of extractions requires local anesthetic throughout the mouth, which creates a challenge. There is a great number of extractions, a full mouth of local anesthetic to be administered in a patient with a documented history of hypertension for non-surgical visits supports the need for sedation in order to reduce the need for re-administration of local anesthetic, keep the patients blood pressure within a manageable range, and prevent excessive peri-operative bleeding. The utilization of general anesthesia is appropriate for this patient and procedure. Therefore, the requested extraction of 13 teeth with general anesthesia is medically necessary for 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 a licensed D.M.D., board certified in periodontology, 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: The patient has requested authorization and coverage for laparoscopy, surgical, gastric restrictive procedure (CPT 43775), laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed (CPT 43281), and esophagogastroduodenoscopy (CPT 43239). The records support a diagnosis of obesity in this patient with a body mass index (BMI) between 37.6 kg/m2 and 41.3 kg/m2. The patient has requested bariatric surgery. Part of the standard evaluation for bariatric surgery involves a psychological evaluation. The patient underwent a psychological evaluation in December 2019. The provider recommended that the patient see a psychiatrist to consider medications and to repeat the psychological evaluation to determine appropriate candidacy for surgery. Her provider recommended six months of nutritional counseling. The records document that the patient has completed two months of nutritional counseling. The patients nutritional counseling notes suggest that she is not an appropriate surgical candidate at this time. Based on the available documentation, the requested laparoscopy, surgical, gastric restrictive procedure (CPT 43775), laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed (CPT 43281), and esophagogastroduodenoscopy (CPT 43239) are not medically necessary for 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 surgery with expertise in minimally invasive and bariatric 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

The patient is a six-year-old female with a history of expressive and receptive language deficits and a severe articulation disorder. Other diagnoses as stated include apraxia, auditory processing dysfunction, speech disorder and lack of coordination.  The patient has been receiving speech therapy for the above dysfunctions since July 2002. Her parents have requested retrospective coverage and reimbursement for speech therapy provided twice per week as well as on-going authorization at the same frequency.  The Health Plan denied the request based on a determination that the therapy at issue was/is not medically necessary.I have reviewed the literature regarding speech therapy in auditory processing disorders and apraxia of speech. The most apparent finding is that there is little consensus regarding the diagnoses of apraxia of speech or auditory processing disorder.  A study by Lewis, et al suggests that apraxia is associated with other learning disabilities (reading and writing deficits) and although the articulation disorder may improve somewhat, the functional deficits do not necessarily improve.  Likewise, the technical report produced by the American Speech-Language-Hearing Association (ASHA) indicates central auditory processing disorders (CAPD) are often associated with difficulties in learning, speech, language (including written language involving reading and writing), social, and related functions. Additionally, the report suggests that because both CAPD and learning disabilities are expressed in countless different ways, it is difficult to distinguish medically based treatment from an educational goal.  In this case, it appears that the most recent goals from the speech therapy progress report dated February 2006 are educational in nature, and not medically based.  Additionally, a review of the literature indicates there is no evidence to support the theory that intensive, or more frequent speech therapy is superior to the therapy provided in the educational setting.  I find no studies that even address the frequency of speech therapy intervention for these types of dysfunction.  Based upon the information set forth above, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 79-year-old male enrollee has requested radiofrequency ablation for the treatment of his renal cell cancer.  Findings:  Three physician reviewers found that the patient is a 79-year-old male with responding advanced prostate cancer. He has a growing kidney lesion suspicious for cancer and is not a good operative candidate. Research data for radiofrequency ablation (RFA) is not likely to ever be at the level required for widespread acceptance or FDA approval. However, carefully selected patients in experienced hands should have similar outcomes at lower risk than with laparoscopic partial or open nephrectomy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female with painful onychomycosis of the fingernails. She is currently taking Remicade and methotrexate for ankylosing spondylitis. Her blood tests, including liver function tests, have been normal. Use of Penlac solution topically has been denied by the Health Plan because the patient has not tried and failed a course of oral Lamisil. The Health Plan further states that Lamisil is not contraindicated in a patient taking Remicade. The treating dermatologists records document the patient is taking both Remicade and methotrexate. The patients letter of June 2006 indicates it is the methotrexate she is taking that is a contraindication to Lamisil.Lamisil tablets are contraindicated for patients taking methotrexate. Both medications are potential causes of hepatotoxicity and use of both medications concurrently would increase the risk of hepatotoxicity. Because oral antifungals are contraindicated in patients taking methotrexate, it is medically necessary for this patient to be treated with topical Penlac solution. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient 30-day rehabilitation treatment program services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the residential level of care.  This patient was motivated to stop drinking, and he had safe housing.  He denied any cross-addiction with other substances.  The patient had no psychiatric comorbidity.  There was no evidence in the record that the patient had previously engaged chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been inadequate.  All told, inpatient 30-day rehabilitation treatment program services provided were not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Upheld

A 61-year-old male enrollee has requested psychotherapy sessions at a frequency of three times per week for treatment of his major depressive disorder. Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of psychotherapy sessions at a frequency of three times per week. Per the submitted documentation, the patient is not currently on an antidepressant.  Additionally, there is no indication that the most effective treatment according to American Psychiatry Association guidelines, electroconvulsive therapy, has been attempted or considered. There is no indication that this patient has a history of inpatient treatment or that he is currently at risk for a higher level of care. In this patients case, psychotherapy sessions at a frequency of three sessions per week was not medically indicated during the time period at issue.  Additionally, there is insufficient data to support ongoing psychotherapy. There is no evidence that he has benefitted from the psychotherapy services or that he is likely to significantly decompensate in the absence of psychotherapy.