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

A 51-year-old female enrollee has requested acute psychiatric inpatient care for treatment of her behavioral health problems. Findings:  The physician reviewer found that it appears that a majority of the patients symptoms have been secondary to opiate withdrawal as opposed to her diagnosis of bipolar disorder. As noted by Schatzberg and Nemeroff, this reaction is typical for patients undergoing opiate detoxification. The submitted records suggest that the patients worsened mood and morale is due to her opiate detoxification than underlying psychiatric pathology.Further, there is no documentation of the patient having any plans to harm herself and there were no self-injurious behaviors noted. She was not documented to be a danger to others, nor was she noted to be grossly disorganized, gravely disabled, delusional or psychotic. Her cognitive status is documented to be alert and oriented per the group therapy notes during the period under review. According to generally accepted guidelines, disturbances in the above are considered a minimum requirement for continued acute inpatient psychiatric stay. Additionally, the therapy group progress notes indicate the patients focus was on her substance abuse issues and not those issues related to the improvement of her bipolar disorder. In conclusion, the patient does not meet the medical necessity criteria for continued inpatient psychiatric hospitalization from the date of service in question forward.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five year-old male enrollee has requested for continued speech therapy and an augmentative and alternative communication (AAC) speech generating device for treatment of the enrollees autism.   Findings:  The physician reviewer found that the speech therapy services are necessary to intensify the treatment regimen. In terms of the requested AAC speech device, the references cited above demonstrate that this device has been shown to be beneficial in augmenting language development in childhood apraxia. The improvements in functional communication are thought to enhance concept formation and reinforce attempts at communication. The device is integrated into speech therapy as a supplemental, rather than replacement, strategy for spoken communication.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee requested authorization and coverage of a referral to a podiatrist for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees ingrown toenail.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested  Nuvigil, 37.5 mg per day for treatment of the enrollees attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that based upon the medical literature, Nuvigil is not considered first-line treatment for ADHD. However, Greenhill and colleagues found that modafinil is effective in the treatment of psychiatric disorders including ADHD. The primary difference in Nuvigil and modafinil, is that Nuvigil has a longer half life, or remains in the blood longer. In addition, one study from Biederman and Pliszka found that children and adolescents who received treatment with modafinil experienced improvement in ADHD symptoms. The authors concluded that, Modafinil improved ADHD symptoms and behaviors in patients with the inattentive and combined subtypes as determined by teachers, investigators, and parents. These findings were confirmed in an evidence-based review by Kumar, who found that modafinil was shown to be effective in large studies of children with ADHD. Given the facts in this particular case and the fact that the patient has been tried on and failed numerous first-line therapies for ADHD, but has responded well to Nuvigil, the requested medication is medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee has requested name brand Paxil for treatment of his anxiety.  Findings:  The physician reviewer found that this patients records indicate that he has been treated with brand name Paxil in the past and it was successful to manage his myriad somatic symptoms of his anxiety. However, there is no indication that he completed an adequate trial of the generic formulation and that it failed to manage his symptoms. Also, there is no indication that he has any adverse effects from taking generic paroxetine. Consistent with these findings, the medical necessity of brand name Paxil is not supported in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level criteria for Clinically Managed High-Intensity Residential Services. The records document the presence of a CIWA score consistent with mild to moderate withdrawal symptoms. The patient has comorbid PTSD and depression. The patient is in the early stages of readiness to change. The provider noted that the patient is reinvigorated and motivated to change. The patient continues to report cravings and his history of multiple relapses support that the patient is at high risk for future relapse. The patient has demonstrated prior difficulty maintaining sobriety in his recovery environment and will return to this same environment following discharge. The patient requires a safe and stable living environment in order to develop his recovery skills. The patient meets the criteria for ASAM Level III treatment, similar to the services provided at the current RTC. All told, the RTC services 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: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for applied behavioral analysis (ABA) services consisting of 20 hours per week of direct one-on-one with a paraprofessional; four hours per week of parent training; three hours per week of supervision; and 0.25 hours per week of social skills group. The Behavior Analyst Certification Board (BACB) has provided evidence-based treatment recommendations for patients with autism. The BACB highlights the critical features of an appropriate treatment plan should include target behaviors that are operationally defined, including baseline levels. The behavioral targets section of the patients treatment plan does not include baseline data and the remainder of the patients goals do not include an objective assessment of the patients current skill levels and deficits. The goals reference the patients current Individualized Education Plan (IEP) or approximations of behavior. This lack of objective data makes it difficult to evaluate the patients progress, as there is no understanding of the patients level of behavior at the onset of treatment. Further, 10 of the 18 goals pull directly from the patients IEP, which highlight an educational rather than medical basis. Additionally, the goals are not linked to specific autism criteria. While the provider noted that the patients goals address autism symptoms such as communication, most goals are general self-help and daily living skills that are not specific to autism spectrum disorder. All told, the requested ABA services consisting of 20 hours per week of direct one-on-one with a paraprofessional; four hours per week of parent training; three hours per week of supervision; and 0.25 hours per week of social skills group 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 a licensed BCBA and board certified in psychology 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 12 additional physical therapy sessions. Kim and colleagues note that scoliosis may present as adolescent idiopathic scoliosis or adult degenerative scoliosis. Berdishevsky note that there are many therapeutic interventions for children with scoliosis, including observation, physiotherapy scoliosis specific exercises (PSSE), and bracing. Lotan and Kalichman note that case reports and small-scale clinical trials of poor methodological quality prevent a clear conclusion about the effectiveness of manual therapy in the treatment of adolescent idiopathic scoliosis. While PSSE are often recommended for the treatment of adolescent idiopathic scoliosis, there is a dearth of convincing evidence from high quality studies that establishes the benefit of these various methods with respect to outcomes such as scoliotic curve progression. Day and colleagues report that there is insufficient evidence to suggest that the Schroth and Scientific Exercise Approach to Scoliosis (SEAS), two types of PSSE methods, can effectively improve Cobb angles in patients with adolescent idiopathic scoliosis compared to no intervention. Romano and colleagues also note a lack of high-quality evidence to recommend the use of PSSE for adolescent idiopathic scoliosis. Plaszewski and colleagues conclude that higher quality reviews indicate that generally there is insufficient evidence to make a judgment on whether non-surgical interventions in adolescent idiopathic scoliosis are effective. In this case, the patient underwent thoracolumbar deformity correction. Postoperatively, he wore a brace and was referred to and underwent physical therapy. While the patient continues to report some symptoms, including at the right shoulder blade region and intermittent popping sensations, the records do not indicate impairments or other outcomes that would be changed or improved with continued formal physical therapy over a home exercise and conditioning program. Therefore, 12 additional physical therapy sessions are not medically necessary for the 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 physical medicine and rehabilitation 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 parent of a 16-year-old female enrollee has requested a custom ACL brace for the treatment of the enrollees anterior cruciate ligament tear. Findings:  The physician reviewer found that a custom anterior cruciate ligament brace was not medically necessary for treatment of the patients medical condition. There is no documentation that this patients condition or body habitus required a custom-made brace. Furthermore, an appropriate alternative was offered by the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested bilateral breast reduction surgery for treatment of her large heavy breasts and related back, shoulder, and head pain. Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS) guidelines, reduction mammaplasty is considered reconstructive surgery and medically necessary for symptomatic macromastia patients with documentation of at least of two of the following: chronic breast pain caused by weight of the breasts; upper back, neck, and shoulder pain; unspecified backache; headache; and shoulder grooving from bra straps. This patients records reference upper back, neck and shoulder pain, shoulder grooving and headache on various evaluations by her providers. Therefore, she meets the ASPS criteria for reduction mammaplasty. In an effort to relieve her symptoms, the patient has been treated with non-surgical methods without substantial improvement. Thus, based on the photographs and documented exams, the requested surgery would offer this patient a more than a minimal improvement in her function and appearance. As such, the requested surgery is reconstructive and medically necessary as it is being performed to provide this patient with relief from her painful symptoms associated with macromastia.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of amale enrollee has requested authorization and coverage for 25 hours per week of applied behavioral analysis (ABA) (0365T), and 12 hours per month of supervision (0369T) for treatment of the autism.Findings:  The physician reviewer found that based on the documentation submitted for review, the request for 25 hours per week of ABA (0365T), and 12 hours per month of supervision (0369T) has been established as medically necessary. In this case, the patient has made progress in many areas as evidenced by the progress reports, however he continues to demonstrate significant delays in social skills, behaviors and adaptive skillsets as measured across multiple domains. In addition, the patient continues to have multiple unmet goals and a high level of self-injury at the frequency of 9.6 times per hour. Thus, there is sufficient support for the ABA hours recommended by the patients provider. All told, the requested services are medically necessary for treatment of the patients medical condition.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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 49-year-old female status post gastric bypass for morbid obesity after an unsuccessful attempt at gastric stapling. She is nearing her pre-bypass predicted ideal weight of 134 pounds. She has undergone a panniculectomy and now wishes to undergo a brachioplasty for redundant hanging skin on her upper inner arms. The Health Plan has denied authorization for a brachioplasty on the basis that it is not medically necessary and is cosmetic in nature.The submitted medical records and photographs of the patient demonstrate hanging skin and subcutaneous fat but no indication of medical necessity for the proposed brachioplasty. There is no evidence of any skin rash or infection on the patients arms. In the absence of documented evidence of a functional impairment, such as a skin condition, which has failed to respond to conservative treatment, the requested procedure is not medically indicated and is cosmetic in nature. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested an X-Stop interspinous process decompression system for the treatment of his spinal stenosis. Findings:  Two physician reviewers found that although some studies of the X-Stop procedure have shown promising early results in limited numbers of patients (Zucherman and colleagues), other studies have not been as favorable and the need for randomized, controlled studies has been implicated (Siddiqui and colleagues). Studies of long-term outcomes and comparisons with laminectomy are in progress, but the results are not yet available. Until outcome data demonstrating the long-term efficacy of the X-Stop is published, the procedure remains of questionable benefit.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee has requested plastazote custom orthotics for treatment of her plantar fibromatosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has severe plantar fibromatosis that has failed to respond to multiple treatments including over the counter arches, rigid orthotics, non-steroidal anti-inflammatory drugs (NSAIDs), narcotic pain medications, gabapentin, and activity reduction. She has also undergone surgeries including aggressive resection and skin grafting, yet her condition has progressed. In addition, her providers have recommended the plastazote custom orthotics for her condition. Since the soft tumors are likely produced and exacerbated from pressure, offloading the area with a plastazote orthotic is medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old female with a long-standing history of smoking.  However, the patient quit smoking approximately 15 years ago. The patient underwent a CT scan of the chest on 7/13/99, which was negative. Chest x-rays performed on 9/9/03 and 9/17/02 were negative except for evidence of chronic obstructive pulmonary disease on the latter exam. CT scans of the coronary arteries performed on 2/28/01 and 7/18/02 were negative. A helical CT scan of the lungs performed on 3/26/04 was also negative. The patient has requested reimbursement for the most recent helical screening CT scan of the chest.Currently, there are several on-going clinical trials evaluating the efficacy of screening CT scans of the chest for lung cancer. This patient may qualify for one of these studies. However, earlier detection of lung cancer by screening CT scans of the chest has not yet shown to decrease mortality from lung cancer and is currently not the standard of practice. Thus, helical screening CT scans of the chest are of unknown efficacy at this time. Therefore, I have determined that the CT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 21-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient presented to the emergency department due to severe discomfort, difficulty walking, urinary hesitancy and urinary frequency. The differential diagnosis for these symptoms includes bladder infection as well as more serious disorders including pyelonephritis and renal lithiasis.  It was important that she was evaluated and ruled out for any life and/or organ threatening disorders and that she received antibiotic therapy.  If she had gone untreated, her pain would likely have gotten worse, and the infection could have spread to her kidneys and/or bloodstream.  From the patients description, she was suffering pain of sufficient severity that a prudent layperson would have reasonably decided to seek immediate medical attention due to fear for jeopardy to her organs and organ function.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the heart monitor (implantable ambulatory event monitor) for treatment of the enrollees chronic cardiac rhythm.Findings:  Two physician reviewers found that based on the records provided the patient has PVCs and NSVT associated with symptoms that are reported to be continuous and without associated syncope. In this circumstance arrhythmia assessment should be able to be adequately obtained using serial Holter monitoring or external event recording. External event recording previously used adequately identified the patients dysrhythmia. Implantable loop recorders are not clinically indicated in this setting, and are generally reserved for infrequent dysrhythmias or symptoms that would not be expected to be identified on shorter term monitoring devices. Implantable loop recorders are typically used in the evaluation of palpitations or syncope of undetermined etiology when symptoms are infrequent, usually less than once per month and/or other ambulatory monitoring has been inconclusive. Final Result: Two reviewers determined that the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement, prospective authorization and coverage for residential treatment center services provided.  Findings:  The physician reviewer found that according to Walsh and colleagues A [partial hospitalization program] PHP is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight (e.g., greater or equal to 80% of ideal body weight) and maintain other evidence of medical stability. The patient did not meet the criteria for orthostatic hypotension. The patient was medically stable, did not have any suicidal or homicidal ideation, and did not have any psychosis, hallucinations, or paranoia that would require 24-hour observation. The patient was motivated for treatment. Therefore, the patient could have been treated in a lower level of care. Final Result: The reviewer determined that the services at issue were not and 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 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.