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

The parent of a five-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature is replete with data in support of speech therapy for young patients with autism spectrum disorder (ASD). Myers and colleagues publication is useful in deciding whether speech therapy is necessary in each individual patient. The authors concluded that, Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, 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. In addition, Goldsteins paper discusses the various techniques that can be successful in developing speech in autistic children. The paper by Turner and colleagues is a controlled comparison of autistic children who did and did not receive speech therapy. The authors determined that the patients who did receive therapy developed far greater communication skills than those who did not receive therapy. The report from the American Speech-Language-Hearing Association (ASHA), states that autistic children can benefit from speech therapy.  In the case of this patient over approximately 18 months the patients receptive language was documented as improving from an 8-9-month level to a 13-month level, which demonstrates that he has the potential for improvement with additional therapy. Therefore, I have concluded that speech therapy is medically necessary for treatment of the patients condition as recommended by his provider.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient was evaluated with a dual energy x-ray absorptiometry (DEXA) scan. Findings:  The physician reviewer found that the report noted osteopenia. The patient endorsed back pain due to L1-L5 compression fractures. The patients provider noted that treatment with Fosamax and Boniva was discontinued due to intolerable side effects. The patient has requested authorization and coverage for Forteo. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this patients case is whether Forteo is medically necessary for the treatment of the patients medical condition. Teriparatide (Forteo) was approved by the U.S. Food and Drug Administration (FDA) in 2002, and there is long-term safety data to support its use. A study found that in postmenopausal women with severe osteoporosis, the risk of new vertebral and clinical fractures is significantly lower in patients receiving teriparatide than in those receiving risedronate. In this case, the patient is a postmenopausal woman with a history of osteopenia. She has failed treatment with two bisphosphonates and has had a fracture while on therapy. The medical evidence supports the requested medication in this clinical setting. Therefore, Forteo is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 59-year-old female enrollee requested authorization and coverage of a STS (sympathetic therapy) machine for the treatment of sjorgren's syndrome and fibromyalgia.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a STS (sympathetic therapy) machineis is not likely to be more beneficial for treatment of the enrollees sjorgren's syndrome and fibromyalgia than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested bilateral mastopexy for the treatment of her bilateral breast ptosis. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. While the patient has evidence of breast ptosis, this is a natural consequence of weight loss and aging. There is no evidence that the ptosis is secondary to macromastia. As such, the patient does not have an abnormal structure of the body. In the absence of evidence of an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning general concepts of medical necessity, this patient has the typical complaints for symptomatic macromastia, but she does not have large breasts. Symptomatic macromastia is a mechanical problem due to the pulling forces exerted by heavy breasts on the musculoskeletal system. Based on her photographs, this patient does not have heavy breasts. Rather, she has involutional ptosis from her weight loss. Although the efficacy of breast weight reduction as a treatment for musculoskeletal strain is well-established, the medical literature provides no evidence that correction of breast ptosis without a reduction of breast weight is an effective treatment for musculoskeletal pain. The plastic surgeons consultation note describes problems with intertrigo, but the medical records do not provide any documentation in the form of primary care physician or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or, despite initial response, have recurred and caused significant functional impairment. Likewise, the records do not include any office notes that document long-standing musculoskeletal symptoms that have failed to respond to conservative treatments. The patient has been treated by a chiropractor, but office notes are not submitted that document the indications and response to treatment. Irrespective of whether the patient has musculoskeletal symptoms, there is no scientific evidence that the proposed treatment will be effective for her complaints. Bilateral mastopexy is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a lumbar epidural steroid injection for treatment of his lumbar disc degeneration.  Findings:  The physician reviewer found that upon review of the submitted clinical documentation, the medical necessity of the requested lumbar spine injection has not been established. Per the medical literature, there is good (level II-2) evidence supporting the use of steroids for treatment of radiculopathy or radiculitis resulting from disc herniation and spinal stenosis. However, the submitted records do not provide confirmatory evidence of radicular symptoms. The patients pain is primarily in the low back with positive facet maneuvers, tenderness over the facets, negative straight leg raise test and no change in motor or sensory function. As such, evidence of radiculopathy or radiculitis is lacking in this case. In the absence of documented radiculopathy or radiculitis, the patient does not meet clinical indications for lumbar epidural steroid injection. Thus, the requested service is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 management 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 53-year-old male enrollee requested authorization and coverage of endovenous radiofrequency ablation. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees varicose veins. Three physician reviewers performed a medical necessity Independent Medical Review. All three physician reviewers concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition. Because all three physician reviewers concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female with previously diagnosed Major Depression, Recurrent and Axis II pathology thought to be in the realm of Borderline. She has been treated with a combination of medications and psychotherapy. The patient received 141 sessions with her therapist from July 2001 to January 2005. She also saw several psychiatrists during this time and was eventually thought to be reasonably stabilized with a combination of Zoloft, Wellbutrin, and Neurontin. Neurontin was added to her regimen due to the concern of the therapist that the patient seemed sufficiently hypomanic to warrant a consideration of bipolar disorder, type II. In consultation with the psychiatrist, the operative diagnosis was changed. The nucleus of the patients symptoms centered on anger, often to the extent of rage, with a tendency to go off, as in yelling at her husband, often in the presence of their young daughter. Some of the rages included fantasies of wringing her husbands neck, though never actually becoming physically assaultive. She also suffered from some sleep continuity disturbances and a periodic tendency to feel suicidal, though there is no evidence of any real intent for such, rather one of the ostensible feeling of simply not wanting to wake up. The focus of therapy centered on the extent of the patients need for control and her rage, and how this played out in her marriage. The submitted notes indicate the patient never reported a suicide attempt.The patient has requested authorization and coverage for continued outpatient therapy. The Health Plan has determined continued outpatient therapy is not medically necessary for treatment of the patients condition.There is nothing in the submitted notes to support the presence of Borderline Axis II pathology. Rather, the included notes seem to point to narcissistic pathology as the source of the patients troubles. Clearly, the patient has no impairment in sense of self or any self-destructive behavior, items one would expect were the patient actually suffering from a Borderline organization. However, that she is a perfectionist, often given to rages, would seem entirely consistent with the notion of narcissism as the preeminent problem. The periodic suicidality is also quite consistent with narcissistic pathology. The patient may well also suffer from bipolar disorder, type II. Nonetheless, the tenor of the notes points to the patient faring relatively well just as often as faring angry, seemingly irrespective of therapy. If anything, the Wellbutrin seemed to provide the most benefit. The patients rage seems to run counter to the notion of fragility. All told, she appears to have had a fair course of therapy for close to four years with nothing to indicate that continued therapy would be beneficial; nor, is she precariously balanced. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks, as in this case. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 internal medicine with sub-specialty certification in 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 a Durolane injection in the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, including only four weeks of relief from a cortisone injection, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Durolane injection in the left knee 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation testing for evaluation of the enrollee, who has a history of high mastoid release syndrome. Findings:  The 3 physician reviewers found that the physician reviewer found MTHFR is an enzyme involved in the metabolism of homocysteine. There is a lack of scientific or medical evidence that the result of genetic testing for MTHFR variants such as 1289c is medically beneficial for the management of medical conditions, including idiopathic mast cell activation syndrome. The American College of Medical Genetics has published a guideline which states there is lack of evidence for the utility of MTHFR polymorphism testing. Thus, MTHFR mutation testing was not likely to be more effective than other methods of evaluating this patient.  Final Result: The 3 reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal 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.Physician reviewer number two is board certified in internal 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.Physician reviewer number three is board certified in internal 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

The parent of a five-year-old male has requested social skills group therapy for treatment of his autistic disorder. Findings:  The physician reviewer found that social skills group therapy is to help facilitate social and play skills in a functional and naturalistic setting. It fosters the development of social skills such as making friends, reciprocal communication, joining groups and using verbal and non-verbal communication. Participants learn these new social skills concepts in a clinical setting and are encouraged to carry the information with them for use at outings in various sites within the community.  Therefore, this treatment is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 20-year-old male enrollee has requested for laboratory tests for evaluation of the enrollees abdominal pain. Findings:  The physician reviewer found that there are no prospective studies in the peer-reviewed literature to demonstrate the utility and efficacy of a celiac sprue panel as a screening test to diagnose Celiac disease. The clinical presentation of celiac disease may be characterized by chronic abdominal pain, but there are no large studies available in the literature showing the actual incidence or prevalence of celiac sprue in patients with abdominal pain. One community-based control study found no association between recurrent abdominal pain and the prevalence of anti-endomysial antibody. A total of 200 children were recruited, of whom 173 (87%) had serum samples drawn. Of these, 92 were children with recurrent abdominal pain and 81 were control participants. Only 2 of the 173 samples (1.2%) were positive for anti-endomysial antibody. The frequency of anti-endomysial antibody positivity in children with recurrent abdominal pain was 1 in 92 (1%; 95% confidence interval, 0-6%) compared with 1 in 81 (1%; 95% confidence interval, 0-7%) in control participants. Therefore, these data do not support screening for celiac disease in the child with classic recurrent abdominal pain in the primary care setting.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided indicating that she did not receive emergency services.Findings:  The physician reviewer found that the patient is a female who presented to the emergency department with reports of diarrhea, rash and vomiting. She had been evaluated the day prior at urgent care and prescribed a Medrol dose pack without relief. On the day of arrival to the emergency department, the patient reported continued rash with lip swelling and wheezing. The patient was admitted for observation, started on IV steroids, famotidine, and Benadryl. The patient was assessed with acute urticarial rash, possible viral gastroenteritis, leukocytosis and hypothyroidism. She was maintaining her airway and no uvular swelling was noted. Her lungs were clear without wheezing. She was discharged on the following day. The patient has requested reimbursement for emergency medical services provided.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric sleeve surgery for treatment of her obesity.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested surgery. Although this patient does have documented obesity with a BMI of at least 35 and hypertension, she is not an appropriate candidate for bariatric surgery as there is no documentation that she has completed a thorough multidisciplinary evaluation that would include a dietary, psychological and surgical evaluation. Therefore, although this patient may be a potential candidate for treatment of obesity, she does not meet the criteria for bariatric surgery. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.