Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for Residential Treatment Center (RTC) services. Findings:  The physician reviewer found that in this case, the submitted documentation does not reflect that the patient had a psychiatric emergency medical condition during the period that he received RTC services. At the time of his admission to the RTC, the patient was diagnosed with cannabis use disorder and bipolar disorder, type I. The submitted records reflect that the patient denied any suicidal or homicidal ideation and did not have any auditory/visual hallucinations or psychosis during the period that he received RTC services. The patients drug screens were found to be negative on multiple occasions during this time period. He had been recently discharged from an inpatient stay where he was to follow up with his provider as an outpatient. At the time of admission to the RTC, the patient was evaluated by an intern and by an attending Doctor of Psychology, and it was determined that the patient was not in an immediate danger to himself or to others, and was not immediately unable to provide for or utilize food, shelter, or clothing due to his mental disorder. Under these circumstances, the Residential Treatment Center (RTC) services at issue did not constitute psychiatric emergency services as defined by California law.Final Result: The reviewer determined that the services at issue were not psychiatric emergency services as defined by California law. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested a continuous passive motion machine for treatment of his status post anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that although the use of a continuous passive motion machine after anterior cruciate ligament surgery is often recommended, the practice has long been a source of controversy.  Evidence of the benefit of the equipment at issue in this clinical scenario is limited, and there is need for further study. Early motion is beneficial for reducing pain and decreasing scar formation that can limit motion, but no substantial advantage has been identified for continuous passive motion machine use. Further study is indicated to improve the evidence base. However, until this evidence is available, continued use of continuous passive motion machine cannot be supported.  At this time, there is a lack of support in the medical literature for the use of a continuous passive motion machine in this patients case.  All told, the continuous passive motion machine was not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) testing for evaluation of the enrollee, who reported a history of weight gain and an episode of gastroenteritis. Findings:  Three physician reviewers found that multiple, evidence-based studies have demonstrated that IgG testing to foods is an unproven method of testing for food intolerances as well as food allergy. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, or that IgG antibodies cause symptoms. The exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease. Final Result: Three 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: All three physician reviewers are board certified in internal medicine and allergy and immunology 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 authorization and coverage of either Aromasin (exemestane) tablet or Arimidex (anastrozole) tablet for treatment of his history of low testosterone levels.  Findings: The physician reviewer found that Aromasin and Arimidex are aromatase inhibitors. They are commonly used in women with breast cancer as it reduces breast cancer recurrence and breast cancer mortality in postmenopausal women with non-metastatic hormone receptor-positive breast cancer. Aromatase inhibitors suppress plasma estrogen levels by inactivating aromatase, the enzyme responsible for the peripheral conversion of androgens to estrogens. This patient is on testosterone replacement therapy for a diagnosis of hypogonadotropic hypogonadism and was started on Arimidex therapy in March 2017 for elevated estrogen levels. However, because estrogen is also an important player in many physiologic functions in men including bone metabolism and cardiovascular health, caution must be exercised, as there is a lack of long-term data on adverse effects on bone and cardiovascular system during treatment with aromatase inhibitors in hypogonadal men. During testosterone replacement, estrogens may rise and occasionally reach elevated levels. As such, there is a lack of evidence that treatment of elevated estrogen levels during testosterone replacement has benefit in this clinical setting. Therefore, both Aromasin and Arimidex are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 28-year-old female enrollee has requested an echocardiogram and an ultrasound administered by a perinatologist for evaluation of her 30-week gestation with ultrasound findings of clubbed foot and uterine fibroid.  Findings:  The physician reviewer found that the widespread use of echocardiography has enabled accurate diagnosis of most heart diseases during pregnancy as it allows non-invasive evaluation of structural and functional cardiac factors. Some normal pregnancy-induced changes include tricuspid regurgitation as well as significantly increased left atrial size and left ventricular outflow cross-sectional area. Indications for the use of fetal echocardiogram may include suspicion or surveillance of cardiac anomalies, maternal exposure to teratogens and evidence of fetal arrhythmias. There is no evidence in this patients records that a fetal echocardiogram is indicated, as there are no findings suspicious for any cardiac anomalies or any of the other indications for such testing. As such, the requested echocardiogram is not medically necessary for this patient.With regard to the patients request for an ultrasound to be administered by a perinatologist, the patient was previously evaluated by a perinatologist who recommended a follow-up ultrasound at 6-8 weeks. Given the presence of a fetal anomaly (club foot), it would be medically appropriate and within the standard of care for the ultrasound to be performed by a perinatologist, as such specialists generally have advanced expertise in the area of fetal development. Therefore, the patients request for a referral to a perinatologist for this procedure is medically necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyosted 75 mg/0.5 mL auto-injector.Researchers have explained that the goal of testosterone replacement therapy is to return serum testosterone levels to within physiologic range and improve symptoms in hypogonadal men. Some of the symptoms aimed to improve upon include decreased libido, erectile dysfunction, infertility, hot flashes, depressed mood, and loss of muscle mass or hair. Currently the routes of delivery approved for use by the United States Food and Drug Administration encompasses buccal, nasal, subdermal, transdermal, and intramuscular (IM). Many factors must be considered when a clinician is choosing the most correct formulation for a patient. As this decision depends highly on the patient, active patient participation is important for effective selection. In this case, the patient has diagnoses of hypogonadism with decreased testosterone and energy levels. The patient has failed clomiphene and topical testosterone gel (AndroGel Pump 20.25MG/ACT, 1.62%), and he has only oral testosterone or injectables/implantables left for therapy. The patients reported needle phobia makes the requested Xyosted 75 mg/0.5 mL auto-injector a rational choice for ongoing therapy. Under these circumstances, the requested medication Xyosted 75 mg/0.5 mL auto-injector is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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 20-year-old male enrollee has requested for additional physical therapy services for treatment of his knee pain/scar tissue formation.  Findings:  The physician reviewer found that There are no functional deficits noted in the submitted records in terms of the patients ADLs. This patient has achieved maximum benefit from skilled physical therapy. Given the absence of functional deficits and the lack of any other documented need for additional therapy, further sessions of PT are not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Viberzi 75 mg tablets, 60 per 30 days. Findings:  The physician reviewer found that iberzi has been demonstrated to be safe and effective for the long-term treatment of irritable bowel syndrome, diarrhea-predominant in high-quality clinical trials. The records provided for review document that this patient has failed the standard alternatives recommended by American College of Gastroenterology (ACG) guidelines for the treatment of irritable bowel syndrome, including antispasmodics and tricyclic antidepressants (Ford, et al.). Moreover, no contraindication to Viberzi is documented. For these reasons, the requested Viberzi 75 mg tablets, 60 per 30 days 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 internal medicine with subspecialty 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: Upheld

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech therapy services with a speech/language therapist that uses American Sign Language (ASL) as opposed to speech therapy services with an ASL interpreter. The records provided for review document that this patient presents with moderately severe hearing loss up to 4000 Hz on the left and normal hearing in the right ear up to 4000 Hz. On testing, the patients high frequencies showed severe hearing loss. As noted in the medical literature, patients with hearing loss can benefit from speech therapy. However, there is a lack of support for this patient to receive speech therapy with a provider who can communicate ASL. Fitzpatrick and colleagues noted that insufficient, high-quality evidence exists to determine whether sign language in combination with oral language is more effective than oral language therapy alone. Overall, the available data suggest that a speech therapist with an ASL interpreter can adequately and effectively communicate with the patient. Therefore, the requested speech therapy services with a speech/language therapist that uses ASL as opposed to speech therapy services with an ASL interpreter 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old man with Bells palsy since December 2002. The submitted records indicate the patient began receiving physical therapy in January 2003. The patient indicates he is still experiencing numbness on the right side of his face and sometimes has trouble controlling his right eye. The patient has requested authorization for continued physical therapy. The Health Plan has denied the patients request indicating that continued physical therapy is not medically indicated.The Health Plans denial should be upheld. The patient has had one year of treatment for his Bells palsy. Based upon the natural history of this disease, significant improvement is not expected after 9-12 months. Given this, additional improvement with continued physical therapy is not expected. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Botox injection for treatment of her medical condition. Three physician reviewers found that the requested Botox injection is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient has a diagnosis of chronic migraine. The submitted records confirm a substantial benefit with Botox treatment with an estimated 18 fewer headache days. Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. Given the support in the peer-reviewed literature and clinical documentation submitted for review, the requested Botox injection was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in neurology and are actively practicing. All three 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

The parent of a five-year-old male enrollee requested authorization and coverage of speech therapy for treatment of the enrollees speech delay.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested speech therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee requested authorization and coverage for 24 Maxalt per month. The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 113 hours per month of one-on-one applied behavioral analysis (ABA) therapy, 14 hours per month of supervision and 12 hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 113 hours per month of one-on-one ABA therapy, 14 hours per month of supervision and 12 hours per month of parent training are medically necessary for treatment of the patients medical condition. In this case, the patient has made progress in many areas, but continues to have significantly problematic behaviors in the areas of self-injury, stereotyped repetitive behavior and elopement. His maladaptive behaviors makes it increasingly difficult for him to be successful in more generalized environments. Decreasing ABA therapy in the context of extreme self-injury is not to be in the best interest of the patient. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Given the clinical documentation provided for review and support in the peer-reviewed literature, 113 hours per month of one-on-one ABA therapy, 14 hours per month of supervision and 12 hours per month of parent training are medically necessary for treatment of the patients autism. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested dental services for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Radiation therapy, as undergone by the patient is known to be associated with xerostomia or dryness of the mouth caused by damage to the salivary glands. The dental literature provides multiple modes to mitigate the increased risk of decay faced by patients with xerostomia. These modes of mitigation include but are not limited to use of sialagogues to increase salivary flow, topical fluorides to increase resistance, diligent home care and preventive care, and dietary adjustment.  With diligent care including these modalities patients with radiation-induced dry mouth are still at a high risk. However, the proposed dental services are not likely to address the patients condition as the deterioration demonstrated may cause restorations to fail. Therefore, given the limited likelihood of potential benefit, the requested dental services are not supported as medically necessary for treatment of the patients medical condition.  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 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.