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

A 46-year-old female enrollee has requested for a consultation for breast reduction surgery for treatment of her large breasts. Findings:  The physician reviewer found that breast reduction surgery can be effective in relieving the symptoms related to large breasts, such as back pain, neck pain and skin breakdown. However, consideration of surgical intervention is not considered medically necessary until it has been established that an individual has failed a course of non-surgical treatment for her symptoms. In addition, there should be evidence of evaluation and treatment of other conditions that could explain the individuals symptoms prior to surgical consideration.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 39-year-old male enrollee has requested authorization and coverage for an ultralight wheelchair due to prior stroke with resultant hemiparesis.  Findings:  The physician reviewer found that Having wheelchair and prosthesis available is most likely to provide the patient with adequate mobility, benefits of functional rehabilitation, and upright gait, which is protective for the patients overall health. Given the support in the medical literature, the requested ultralight wheelchair is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for retinoblastoma susceptibility gene (RB1) genetic testing. The Health Plan has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees family history of retinoblastoma. Full testing of the RB1 gene is not clinically indicated for this patient. However, testing specifically for the mutation previously identified in her family members is medically necessary to determine if she has inherited the same mutation, if she is at risk for RB1-related cancers, and if she has risk of having affected children. In this case, the patient has a known family history of retinoblastoma. The specific mutation of p.R661W is known to have reduced penetrance, which means that not all those who inherited this mutation will develop retinoblastoma or other RB1-related cancers. There has been an identified parent-of-origin effect with this mutation. Though exact reasons remain unclear, this is likely due to imprinting effects. Therefore, testing for the family mutation would provide useful information for both medical management and reproductive planning for this patient. As such, single-site testing for the RB1 mutation identified in her family members has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested testing is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in clinical biochemical genetics 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 patients parent has requested reimbursement for neuropsychological testing. Findings:  The physician reviewer found that he American Psychological Association (APA), neuropsychological testing is recommended when initial assessment or assessment over time is needed to measure cognitive or functional deficits in patients based on an inability to develop expected knowledge, skills or abilities as required to adapt to cognitive, social, emotional, or physical demands, or evaluate primary symptoms of impaired attention and concentration that occur in neurological and psychiatric conditions. Per the APA, neuropsychological testing evaluation services typically include integration of patient data with other sources of clinical data, data interpretation, clinical decision making, and treatment planning and report. In this case, the patient continued to struggle despite years of accommodations and interventions, as well as previous psychological testing. She showed an inability to develop expected knowledge, skills or abilities as required to adapt to cognitive, social, emotional, or physical demands. She demonstrated difficulties with academic, social, behavioral and emotional realms with conflict at home, poor grades, social difficulties, and symptoms of depression and anxiety. She also has a long history of ADHD and low achievement in mathematics relative to her intellectual ability, as evidenced by her poor grades despite average range intelligence. Per the APA and American Academy of Child and Adolescent Psychiatry (AACAP) recommendations, neuropsychological testing was the next reasonable next step in this patients treatment. For these reasons, the neuropsychological testing provided was medically necessary for 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Stelara 45 mg/0.5 mL subcutaneous solution. According to the American Academy of Dermatology (AAD), Stelara is the preferred agent for pediatric patients with psoriasis who are 12 years of age and older. This patient has severe scalp and ear psoriasis with involvement of 5% of her BSA. The patient reports pain and self-consciousness related to her skin condition. The records provided for review document that the patient has failed treatment with multiple topical steroids over the course of more than one year. Treatment has included topical fluocinonide ointment, ketoconazole shampoo, and clobetasol solution. Currently, treatment with methotrexate or cyclosporine is not recommended for long-term use in pediatric patients with psoriasis. Given these findings, the requested Stelara 45 mg/0.5 mL subcutaneous solution is medically necessary for 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 dermatology 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 two-year-old male enrollee has requested speech therapy for one hour per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Thus, speech therapy is the standard of care modalities for patients with speech delay. Given this patients deficits, it is medically necessary for this patient to receive the requested speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested single stage anterior-posterior decompression and stabilization of the cervical spine for medical treatment of his neck pain and cervical spondylosis. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for surgical procedure, single stage anterior-posterior decompression and stabilization of the cervical spine has not been established. According to the medical literature, cervical discectomy and fusion is a treatment option in patients who have evidence of radicular symptoms, cervical instability, myelopathy due to degenerative, traumatic, infectious, inflammatory and/or oncological processes, and/or failure of previous fusion as verified by diagnostic imaging that is associated with severe pain, motor deficits, reflex changes and neuropathy that results in significant functional limitations that persists despite 6 to 12 weeks of conservative treatment. Additionally, the medical literature states that surgical fusion may be recommended in patients who have failed a reasonable trial of conservative management or in patients who have incapacitating pain or progressive neurological deficits. The authors further indicate that non-operative treatment should consist of a nonsteroidal anti-inflammatory medication, immobilization, traction, physical therapy, and steroid injections. In this case, there is lack of evidence that the patient has subjective physical findings of radiculopathy. Additionally, there is no evidence of significant spinal pathology on imaging study that would support the medical necessity for surgical intervention such as evidence of severe foraminal or central canal stenosis or severe instability. Furthermore, there is lack of evidence that the patient exhausted conservative treatment. For the reasons provided, the request for surgical procedure, single stage anterior-posterior decompression and stabilization of the cervical spine is not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prolia injection. Findings:  Three physician reviewers found that the Prolia injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient is intolerant to treatment with Fosamax. Treatment for Prolia is clinically indicated for treatment of the patients osteoporosis and intolerance to Fosamax. Based on the clinical documentation submitted and peer-reviewed literature, the service at issue was likely to be a more beneficial treatment than standard medical therapy in this clinical setting. Final Result: 3 of 3 reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three Physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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:  The enrollee is requesting reimbursement for foot orthotics. At a podiatry visit, the enrollee reported her problem started when she rolled her right ankle and broke her fifth metatarsal bone. The podiatry assessment indicates chronic right ankle instability secondary to malunion fracture of the fifth metatarsal, creating right foot varus, peroneal tendinopathy right, peroneal tubercle exostosis right calcaneus, pes cavus, and bilateral hammertoe deformity. The podiatrist indicated because of the varus position of her right foot, the enrollee will chronically have ankle instability; her lateral ankle ligaments are extremely dysfunctional and do not have the tension/ability to keep her ankle from rolling. This has caused her peroneal tendons to be overused and to develop cystic changes. The enrollee underwent surgical treatment for primary repair of a ruptured right peroneus brevis and longus, excision os peroneum right, ostectomy calcaneus right, and peroneus longus transfer to brevis right. A podiatry progress note indicates the enrollee was still complaining of pain on the outside of her right foot and ankle. She has difficulty walking and standing and did not believe she could return to her job. She also was in the intensive care unit three weeks prior for an infection, unrelated to this surgery. The podiatrist reminded her that her peroneal tendons will continue to be tender and strained until the next sequence of her reconstructive foot surgery can be finished. In the interim, her podiatrist prescribed an ankle foot orthosis as the only way to stabilize her ankle and prevent her peroneal tendons from rupturing until her surgical treatment is completed. The record indicates the enrollee also requested foot orthotics. Consistent with providers recommendation for ankle-foot orthosis (AFO), literature supports the AFO can be fixed or articulated to permit ankle range of motion, and stabilize the ankle instability. However, the foot orthotic is not medically indicated for ankle instability. As per a study in the medical literature, shoe inserts are recommended for foot pain caused by midfoot arthritis. However, this enrollee is at a high risk for rupturing her peroneal tendons if not stabilized by an appropriate orthosis. Since foot orthotics, such as shoe inserts, cannot stabilize the enrollees ankle instability, the foot orthotic was not medically necessary for the treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis. The provider noted the patient has been treated with viscosupplementation injections, a corticosteroid injection, and knee bracing. The provider also noted a right knee x-ray revealed severe patellofemoral compartment degenerative changes. The patient reported right knee pain. The provider noted that the patient had been successfully treated with Synvisc injections in 2018. The patient has requested authorization and coverage for a Synvisc One injection in the right knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc One injection in the right knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients 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. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of good response to prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections and bracing, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc One injection in the right 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: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for mental health residential treatment center (RTC) level of care services. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. Though the enrollee had a history of substance use, she had managed this issues during her admission. She has supportive resources, but still demonstrates a lack of understanding about her illness. She has not gained complete control over her symptoms. The enrollees composite LOCUS score correlates with Level IV, medically monitored, non-residential services.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested a 24-week course of Sovaldi 400 mg and ribavirin 600 mg for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the 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, regardless of fibrosis, should be treated - except those with life expectancy less than 12 months due to nonliver-related comorbid conditions (Class I, Level A recommendation). For the reasons provided, the request for the proposed medication combination is medically necessary for treatment of the patients HCV.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the chest. Findings:  The physician reviewer found that the American College of Radiology (ACR) lists MRI of the chest in a patient with likely non-cardiogenic chronic chest pain as having a relative value of 2/9 which is low on the probability scale of being useful. In contrast a three phase radionuclide bone scan has a value rating of 4/9, which is somewhat improved. The records provided for review do not demonstrate that this patients symptoms are likely related to cardiogenic causes. In addition, there is no chest x-ray or rib series radiographic report in the submitted records. Based upon the information provided in the chart, the requested MRI of the chest is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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.