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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for requested authorization and coverage for Nutropin AQ Nuspin.In this case, the patients height, growth velocity, bone age, and pre-pubertal findings were normal. MRI of the pituitary was also normal. His family history does not contribute to diagnosis of a disorder involving growth or pubertal progression. Based on the submitted documentation, the patients predicted adult height is close to 67 inches, and his mid-parental height is 68.6 inches. His predicted adult height is within the normal range for his family and within the normal range for North American males. He does not meet generally accepted U.S. Food and Drug Administration (FDA) approved diagnostic criteria for idiopathic short stature, since his height is above -2.25 standard deviations. Growth hormone provocative tests should not be used as the sole diagnostic criterion for diagnosis of growth hormone deficiency, because such tests are prone to false results for multiple reasons. Thus, Nutropin AQ Nuspin is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 63-year-old female enrollee has requested skilled nursing facility services for the skilled rehabilitation/treatment of her multiple medical problems. Findings:  The physician reviewer found that the patient did not progress with OT or PT. Her participation was limited in the last three days of therapy and she had not shown the ability to progress beyond the stand-by assistance and minimal assistance levels. Despite her serious diagnoses, the patient did not require daily skilled nursing intervention due to a changing medical condition, wounds, or injections. Monitoring of coagulation status during Coumadin therapy is a standard outpatient procedure and did not require inpatient care. The patients subsequent acute illness was not evident in the days preceding it. The patient had no daily skilled nursing needs and she had reached the maximum functional level attainable through skilled PT and OT.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with recurrent major depression and borderline personality disorder who was seen in weekly dialectic behavioral therapy for the past year through December 2004. During this time, the patient was on Zoloft with dosage varying between 150mg and 175mg per day. She has requested authorization for continued weekly psychotherapy; the Health Plan recommends every other week therapy in addition to monthly visits with her psychiatrist.A review of her therapists notes indicates that on 7/6/04 the therapist noted the patient continues to state that she has always wanted to kill herself and that feeling will never change. Client was cooperative, pleasant - outside of her commitment to being suicidal and actually stated that she feels happy that she has been granted SSDI benefits. She insists that she be treated as fragile. It is important that this writer remember that the patient is not fragile-she will not melt down if she is pushed to use her skills. Notes from 10/9/04, 10/22/04, 10/29/04 and 11/12/04 discuss the patients application for admission to UCLA and her related anxiety surrounding the application process. On 12/10/04, it was noted the patient and her therapist worked together on a chain analysis on the patients discomfort with her study partner. Notes from 12/21/04 indicate the patient was seen on that day because she was going to be away for the next two sessions and was experiencing intense depression. The patients therapist reported the patient did not want to connect the intensity of this depression to the holiday or the uncertainty about whether she passed her courses.Based upon the information provided, it does not appear the patients antidepressant course changed during this time.Upon review of the therapists notes the patient does not appear to be grossly distressed and, in fact, was even noted by the therapist on 7/6/04 as not fragile. Furthermore, a good bit of what appears to have gone on for months pertains to helping the patient with her application to UCLA, which though important in the entire scheme of all things therapeutic for the patient, was not needed on a weekly basis. The patients reported chronic thoughts of dying are consistent with her diagnosis of borderline personality disorder. The submitted records indicate the patient was cooperative and pleasant and her energies were directed toward entering UCLA. Based upon the submitted therapy notes and the patients history, every other week therapy as offered by the Health Plan is medically reasonable and appropriate. Accordingly, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of residential mental health and substance use treatment in a wilderness residential program. Findings:  The physician reviewer found that the patients presentation had a composite score of 17 on the Adolescent Level of Care Utilization System (CALOCUS). A score of 17 correlates with a treatment intensity level of three, which is consistent with intensive outpatient services. Given these findings, the patient did not require the supervision and monitoring of 24-hour residential mental health treatment. Thus, the residential mental health and substance use treatment was not medically necessary for treatment of this patients behavioral health issues. 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 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: Upheld

A 39-year-old male enrollee requested authorization and coverage of a wireless endoscopy. The Health Plan denied the request indicating that the requested wireless endoscopy is not medically necessary for treatment of the enrollees gastrointestinal problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested wireless endoscopy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a water circulating cold pad with pump for treatment of his medical condition.  Findings:  Two physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the equipment at issue.  Adie and colleagues noted that potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or too low for all main outcomes.  Kraeutler and colleagues compared compressive cryotherapy versus icepacks on postoperative patients undergoing arthroscopic rotator cuff repair or subacromial decompression.  The authors reported that there does not appear to be a significant benefit to the use of compressive cryotherapy over standard ice wrap in this setting.  Therefore, the water circulating cold pad with pump was not likely to have been of greater benefit than other treatment options in this patients case.  Final Result: Two reviewers determined that the equipment 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 reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her risk for breast cancer. Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Overturned

A 67-year-old female enrollee has requested authorization and coverage for breast reconstruction surgery (removal of supernumerary breast axilla) for treatment of the enrollee, who is status post bilateral breast reduction.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure in this patients case.  The medical records document an illness or disease related to the excess left axillary tissue (cellulitis) for which medication was prescribed.  In this clinical setting, direct removal of the left axillary skin fold is medically indicated.  In this patients case, the axillary skin folds constitute an abnormal structure of the body.  This abnormal structure of the body has resulted in skin infections of the fold.  The requested surgery will be performed to improve function by removing the cause of the infection.  Additionally, the surgery will also provide improvement in the appearance of the patient by removing the axillary fold.  All told, the requested breast reconstruction surgery (removal of supernumerary breast axilla) is reconstructive in nature and is medically necessary 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 Elestrin gel. According to the American College of Obstetricians and Gynecologists (ACOG), systemic hormone therapy, with estrogen alone or in combination with progestin, is most effective for vasomotor symptoms. For vulvovaginal atrophy leading to sexual dysfunction, topical estrogen formulations are the most effective. Current data suggests that tablets, gels, creams, and vaginal rings are equally effective. The records indicate that this patient is status post surgical menopause. She was treated with systemic oral estrogen for her menopausal symptoms, which was changed to a transdermal route. The patient cannot tolerate treatment with patches, but experienced good results with Elestrin gel. All told, the requested Elestrin gel is supported as medically necessary for treatment of this patients vaginal atrophy. 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 obstetrics and gynecology 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 46-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that according to the American Academy of Neurology guidelines, botulinum neurotoxin injections should not be considered in patients with episodic migraine and chronic tension-type headaches.  Shuhendler and colleagues noted that the use of botulinum toxin A for the prophylactic treatment of episodic migraine headaches was not significantly different from placebo, both from a clinical and statistical perspective.  At this time, the medical evidence does not support the use of Botox in this clinical scenario.  In this patients case, Botox injections are not likely to be superior over all other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on overall evaluation of the medical literature, including positive reports of therapeutic interventions in children with autism, the requested therapies are clinically indicated and appropriate for assistance in improving this patients communication skills and functional self help skills (Myers, et al). At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus specific treatment, including speech therapy can be used to help induce brain plasticity. As reported by Turner and colleagues on 7-year follow-up, Early characteristics that predicted outcome status were: age of diagnosis, age 2 cognitive and language scores, and total hours of speech-language therapy between ages 2 and 3. The authors concluded that, Language outcomes were also positive at follow-up; 88% of the sample demonstrated at least some functional language, and 32% were able to engage in conversational exchanges. Overall, the requested speech therapy has been shown to improve patient health outcomes in autistic children and therefore should be approved as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The mother of an eight-year-old male enrollee requested authorization and coverage of occupational therapy for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees traumatic brain injury.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested temporomandibular joint (TMJ) dysfunction treatment (CPT code 99354, prolonged physician services) for treatment of his TMJ dysfunction. Findings:  The physician reviewer found that the evaluation of patients with orofacial pain is generally more involved than a routine dental patient. The exam consists of a detailed history and a thorough physical exam of the head and neck. In this patients case, an extended new patient exam was coded for and appropriate for the work-up of the patient. However, given this, it is unclear for what additional purpose a prolonged physician service was also coded for in that there was no documentation submitted to support this additional billed code.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi, Pegasys and ribavirin for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two 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 limited life expectancy (less than 12 months) due to non-liver-related conditions.  For patients with HCV genotype 6, AASLD/IDSA guidelines recommend Sovaldi and weight-based ribavirin with peginterferon. In the phase III NEUTRINO trial, treatment-naive patients with HCV genotype 6 were treated with sofosbuvir plus peginterferon 2a  and weight-based ribavirin for 12 weeks. All six patients with HCV genotype 6 achieved sustained virologic response.  In addition, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Sovaldi, Pegasys, and ribavirin is medically necessary for 12 weeks in this patients case. Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for the advanced lipoprotein testing for evaluation of the enrollees hypothyroidism. Findings: Three physician reviewers found that in these circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Moreover in this case the patient presents with known coronary disease and high intensity statin therapy is indicated regardless of results of specialized lipid testing. Therefore, the advanced lipoprotein testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is 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: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that there were no prior mammograms available for comparison.  There were no masses, however, there was an area of clustered indeterminate calcifications in the anterior third of her left breast.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, this mammogram demonstrated what were felt to be suspicious clustered calcifications.  Tomography has been shown to be of value in better delineating and characterizing calcifications. One aspect of tomosynthesis is that it can better determine that the calcifications are, in fact, clustered, and not simply superimposed.  It is still not unreasonable, as this was a screening study, for the patient to return for specific spot compression and possibly magnification views.  In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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: the physician 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.