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

The parent of a six-year-old male enrollee has requested socialization classes for treatment of the enrollees attention deficit/hyperactivity disorder and oppositional defiant disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a lack of support for the requested socialization classes in this clinical setting.  The patient was described by his parent as well-behaved when behavioral therapists are present.  The parent reported that the patient was aware of how he should act around certain people.   Therefore, the records do not indicate a lack of knowledge, but a lack of behavioral control.  Behavioral modification, parent training, and continued work on finding the appropriate medications are the medically appropriate treatments for this patient.  All told, the requested socialization classes are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation services. The submitted documentation supports the medical necessity of the requested services. This patients depression is treatment-resistant. Per the records, multiple antidepressants and augmentation strategies have not successfully brought on remission. A researcher reported that transcranial magnetic stimulation had a moderate effect on treatment-resistant depression. Medical literature and studies showed that transcranial magnetic stimulation was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Transcranial magnetic stimulation is an effective treatment which has been approved by the U.S. Food and Drug Administration for patients with treatment-resistant major depressive disorder. Therefore, the requested transcranial magnetic stimulation services are medically necessary for the 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 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 51-year-old female enrollee has requested a radioactive iodine uptake test for evaluation of the enrollees history of multinodular goiter with bilateral thyroid nodules.  Findings:  The physician reviewer found that the algorithm for the evaluation of a multinodular goiter is well-established within the peer-reviewed literature.  Leenhardt noted that there is a systematic algorithm for the evaluation of thyroid nodules based on physical examination, clinical history, measurement of thyroid stimulating hormone, and neck ultrasound, which has become the preferred radiologic modality for imaging thyroid disease. Per Leenhardt, radionuclide thyroid scanning is reserved for the evaluation of patients with suppressed thyroid stimulating hormone levels.  The use of nuclear uptake and scan studies is limited to patients with abnormal thyroid function, to evaluate ectopic thyroid tissue, or to determine if a neck mass has active thyroid tissue.  When a patient has a dominant or solid thyroid nodule identified on thyroid ultrasound that needs further evaluation, the examination of choice is a fine needle aspiration of the thyroid nodule.  This is documented in multiple medical articles and is the recommendation of the American Thyroid Association. This patient had a known multinodular goiter with no documentation of abnormal thyroid function.  The patient has had a thyroid ultrasound and had a dominant solid thyroid nodule.  In this clinical situation, the requested testing is not medically necessary.  All told, the requested radioactive iodine uptake test is not medically indicated for the evaluation of this patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for medical services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The medical services provided were not necessary for treatment of an emergency medical condition. The patients parent states the patient was unable to eat properly due to the labial frenum attachment and the mother was developing mastitis from the patients inability to suckle effectively. While some researchers have postulated that the high labial frenum attachment can interfere with the ability to breastfeed, the medical literature does not provide a consensus demonstrating a causal relationship nor improvement after surgical release. Research has shown that there is high variability in the position of attachment of the labial frenum on infants and attachment is quite common. Moreover, there is no clinical documentation supporting a medical condition of failure to thrive. Given the lack of clinical documentation demonstrating an emergent medical condition, the patient did not receive emergency medical services for an emergency medical condition. 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 dentistry 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 has requested authorization and coverage for a custom wrap around solid ankle foot orthosis (AFO). Based on the records provided for review, a custom wrap around solid AFO for the right ankle is not medically necessary for treatment of this patient. The documentation does not reveal objective evidence of osteoarthritis on imaging studies, weakness on a physical examination of the right ankle or foot, or objective findings of ligamentous instability on the right ankle or foot. There is no evidence that the patient has tried and failed a standard prefabricated AFO. A review of the literature reveals that prospective long-term studies are needed to evaluate the association between orthotic use and foot structure in the development of osteoarthritis. Given these findings, the requested custom wrap around solid AFO is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

A 58-year-old male has requested coverage for past anesthesia services provided during a colonoscopy.  Findings:  The physician reviewer found that the American Society of Anesthesiologists' (ASA) position statement is that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist is considered a sufficient level of sedation. MAC is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the ASA, MAC should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. MAC care includes a pre-procedure visit, intra-procedure care and post-procedure anesthesia management. The American College of Gastroenterology states that the use of deep sedation, or MAC, is medically necessary when there is documentation by the endoscopist and anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe co-morbidity, history of anticipated intolerance to standard sedatives, patients younger than 12 years of age or older than 70 years, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation. The review of the medical documentation indicates the patient had no specific medical co-morbidity that necessitated the use of MAC for the elective colonoscopy. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist. The review has determined that the colonoscopy performed did not require the services of an anesthesiologist such that MAC was not medically necessary to perform the procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for the evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis often allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Final Result: Two of the 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ROM Plus rupture of membranes laboratory test (CPT code 84112). Qualitative immunochromatographic testing for rupture of membranes such as ROM Plus have been approved by the U.S. Food and Drug Administration (FDA). However, the current standard of care for a diagnosis of rupture of membranes includes three elements from an evaluation of vaginal fluid including ferning, nitrazine positive findings, and pooling. Tests such as ROM Plus have been shown to have higher false positive results than the current standard of care. The American College of Obstetricians and Gynecologists (ACOG) supports the use of ROM Plus as a second option in cases where traditional testing is equivocal, or the clinical situation is high-risk. In this case, the patient presented with no risk factors to support use of ROM Plus in lieu of standard testing to rule out rupture of membranes. Thus, the ROM Plus rupture of membranes laboratory test (CPT code 84112) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the ROM Plus rupture of membranes laboratory test (CPT code 84112) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: The 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 reviewers 1, 2, and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male has requested past and future coverage for continuation of skilled nursing facility services for treatment of his metastatic melanoma to the brain and lungs.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  As of the date at issue, he required maximum assistance with all transfers.  Despite skilled level of care physical therapy services, he could only ambulate 50 feet with a front-wheeled walker, and he required two people for assistance.  Per the submitted medical records, the patient was receiving no skilled level of care nursing or therapy services.  He was tolerating his medical regimen, and he had no complex wound care issues.  The patient did not require further diagnostic studies or therapeutic interventions.  There was no documentation indicating that the patient was expected to make any further measurable gains in a predictable period of time with continued skilled nursing facility level of care.  Thirteen days after the date at issue, he did not require daily skilled level of care services to prevent deterioration with mobility or activities of daily living.  From this date forward, the patients needs were custodial in nature.  All told, skilled nursing facility services from this date forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a three-year-old male enrollee have requested for neurofeedback for treatment of the enrollees autism. Findings:  The physician reviewer found that Neurofeedback is not currently within the standards of good medical practice for the treatment of autism within the organized medical community. There have been a few small studies utilizing neurofeedback in autism, mostly in high-functioning individuals. One study had matched controls, but was not blinded and the outcome measure was subjective (parental report of functioning).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Psychiatric Association (APA) treatment guidelines state that RTC or similar care higher than outpatient be recommended for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Per the American Society of Addiction Medicine (ASAM) guidelines, this patient meets ASAM criteria for clinically managed high-intensity residential services such as RTC level of care. For dimension 1, intoxication/withdrawal potential, the patient has demonstrated withdrawal symptoms of palpitations, elevated blood pressure, and body aches. The records also note tremors, sweating, fatigue, and agitation. For dimension 2, biomedical issues, the patient has shown weakness, coordination problems, and poor sleep. For dimension 3, emotional, behavioral and cognitive issues, the patient has bipolar disorder and PTSD. For dimension 4, readiness to change, the patient has been pre-contemplative regarding steroid use and remains ambivalent about sobriety. For dimension 5, relapse/continued use problem potential, the patient minimizes the seriousness of his condition and remains unaware of his triggers. For dimension 6, recovery environment, the patient has strained relationships. Given the severity of the patients illness, the RTC services provided were and are medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue 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 with expertise in addiction 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested Botox injections for the treatment of her lumbosacral and gluteal pain. Findings:  Two physician reviewers found that this patient has low back and gluteal pain, with diagnoses of sacroiliitis, piriformis syndrome, trochanteric bursitis, degenerative disc disease and chronic pain. She has been maintained on a variety of pain medications as well as a wide variety of pain interventional treatments. The medical records indicate that prior Botox injections gave minimal pain relief. A later note indicates that only Botox injections had resulted in significant benefit. The patients pain has been refractory to physical therapy, transcutaneous electrical nerve stimulation (TENS) and ultrasound. Botox injections are not a generally accepted medical intervention for the treatment of tightened muscle pain syndromes such as piriformis syndrome. While studies of the treatment of piriformis syndrome with Botox have shown potential for benefit, there is no class I data available to confirm efficacy. No significant trials have been performed demonstrating that Botox is clinically advantageous in the treatment of piriformis syndrome. Thus, there is insufficient peer-reviewed literature to support the efficacy of Botox injections for the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for transforaminal epidural steroid injection. The enrollee has lumbago, sciatica, and long term use of opiate analgesics. The enrollee received a right lumbar transforaminal nerve block. He later reported his pain has improved 60 percent since the nerve block, but the pain had returned three weeks prior. The enrollee described his pain as severe, affecting activities and sleep. He reported his pain rating as a nine on the one-to-ten pain scale. He was also experiencing numbness and a pins-and-needles sensation. He has tried non-steroidal anti-inflammatory drugs with no relief. He takes Norco every eight hours and Robaxin twice a day. His current pain medication regimen has not improved his pain. The enrollee received another right lumbar transforaminal nerve block. The enrollee has tried conservative therapy, including physical therapy and opiates, without substantial pain relief. He achieved symptom relief with two prior transforaminal epidural steroid injections. Literature shows epidural corticosteroid injections were associated with reductions in pain. A systematic review supports epidural steroid injection. Researchers report high-quality trials provide strong evidence for short-term benefit, and at least one high quality trial provided moderate evidence for long-term benefit of transforaminal epidural injections for managing lumbar disc herniation in terms of pain relief and functional improvement.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested for laparoscopic adjustable gastric banding for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 41, this patient meets the National Institutes of Health criteria for weight loss surgery. She has completed a thorough multidisciplinary evaluation that did not reveal any obvious medical, metabolic, dietary or behavioral barriers to surgery. Furthermore, she has failed conservative and supervised weight loss attempts. Additional attempts at conservative measures are not likely to be successful for this patient.