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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center level of services for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Per the medical records, adequate services could not have been delivered in a less restrictive setting.  This patient had a very serious addictive illness complicated by a co-occurring diagnosis of major depressive disorder.  Her addictive illness dominated all domains of her life and undermined her developmental task of identity formation.  She did not have an experiential foundation to draw upon to negotiate intrapsychic and interpersonal stressors.  Further, she had failed treatment in a less restrictive setting during the episode of illness and was at high-risk for a poor outcome in the absence of appropriately matched care.  Upon admission, the patient was demonstrating symptoms consistent with a withdrawal syndrome and the record reflects a difficult detoxification.  It is more than likely that an outpatient detox would have failed and culminated in relapse.  Thereafter, the patient addressed her continued cravings, stunted insight, limited coping strategies and self-defeating behaviors by engaging the full range of services afforded by the setting.  The current medical evidence supports the services at issue in this clinical setting.  All told, residential treatment center services were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee has requested for vertebral angioplasty and stenting for treatment of his cerebrovascular atherosclerotic disease. Findings:  Three physician reviewers found that limited scientific evidence available, there is currently insufficient data to assess the effects of percutaneous transluminal angioplasty with or without stenting or primary stenting for basilar artery stenosis. In this patients case, there is a lack of support for neurosurgical intervention. The current literature has not yet demonstrated the superior efficacy of vertebral angioplasty and stenting as compared to alternative treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female enrollee has requested continued speech therapy for the treatment of the enrollees apraxia and phonological disorder. Findings:  The physician reviewer found that this patient has carried the diagnosis of apraxia and has received speech and language therapy in the past for this diagnosis and articulation difficulties. The literature supports the use and medical necessity of speech and language therapy for verbal apraxia. This patient underwent a speech and language evaluation in July 2007. Results from administration of the Kaufman Speech Praxis Test revealed a severe apraxia disorder. As a result of comprehensive testing, it was determined that her speech and language deficits could not be explained by oral structural deficits, hearing impairment, sensorimotor pathology, environmental factors, or cognitive-linguistic impairment (phonological disorders). According to the literature and the standard of care, continued speech and language therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A forty year-old female diagnosed with diabetes mellitus type 1 is requesting authorization for an Insulin Management System.  Reviewers Findings:  The reviewing physician found that this is a new product and its performance and viability have not been established to the same extent as many other insulin pumps with proven performance.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee requested a power wheelchair for medical treatment of the enrollees knee and foot pain.  Findings:  The physician reviewer found that a power mobility device is not medically necessary given that the records do not establish any mobility deficits in the home that would not be more appropriately addressed by other means.  In addition, there is no documentation of physical examination findings, imaging findings or other objective findings that establish upper limb, cardiovascular or other pertinent organ system impairment that would preclude manual wheelchair propulsion for accomplishing mobility-related activities of daily living outside of the home.  The patient has multiple chronic health conditions which would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for patients with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old male with a history of hepatitis C who is status post liver transplant. Post transplant he has experienced complications of recurrent hepatitis C and bridging fibrosis. His providers have recommended initiating therapy with interferon and ribavirin. He has had the same transplant team for over two years. The Health Plan is denying coverage for services with the patients current transplant providers and has recommended the patient transfer care to other specialist. This patient has a significant and complicated history during which he has been under the care of the same team of providers. In addition, it appears he is beginning or has begun significant therapy with interferon and ribavirin. Given the patients history, current condition and treatment plan, for reasons of continuity of care it is medically necessary for the patient to remain under the care of his current providers. The patient should remain with his current providers for at least another six months. During that time period an appropriate transition plan to new providers can be developed. Currently, it is reasonable and appropriate for the patient to remain with his current providers. Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The patient should remain with his current providers for at least another six months. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested a TLSO brace for the treatment of her condition. Findings:  The physician reviewer found that this brace appeared to be reasonable in this setting. In particular, it was not being utilized as a tool to determine the efficacy of fusion, but rather utilized in an effort to offer some degree of better pain relief than the originally prescribed brace and to be considered as a source of postoperative immobilization following this spine surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee requested muscle-skin graft head/neck (CPT code 15732) and acellular derm matrix implant (CPT code 15777 for treatment of her fascia torn on neck/back after spinal cord tumor removal.   Findings:  Two physician reviewers found that this patient presents with a fascial hernia of the trapezius muscle. She has pain and her provider has recommended repair of the trapezius. The two referenced case reports describe successful repair of non-abdominal fascial hernias with acellular dermal matrix. In addition, numerous studies support a role for acellular dermal matrix in the management of abdominal wall hernias. The surgeons plan to repair the muscle dehiscence and to reinforce the repair if necessary with acellular dermal matrix is therefore reasonable and consistent with the studies supporting the efficacy of acellular dermal matrix for abdominal wall and extremity hernias. For these reasons, the requested muscle-skin graft head/neck (CPT code 15732) and acellular derm matrix implant (CPT code 15777) is likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for Inspire Upper Airway Stimulation system. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea (OSA) in patients who are intolerant or unable to achieve benefit with positive pressure therapy. A meta-analysis by Gillespie and colleagues has demonstrated clinically significant decreases in observed mean AHI scores and improvements in quality-of-life scales. The stimulation treatment for apnea reduction (STAR) trial showed upper airway stimulation provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a five-year follow-up. This patient has failed multiple management modalities including continuous positive airway pressure (CPAP) with different masks and dental appliances with continued OSA symptoms. Therefore, the requested Inspire Upper Airway Stimulation system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment services for treatment of his schizophrenia.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patients longitudinal history and symptom inventory, along with his complex pharmacotherapy that includes high-dose clozapine which is a medication typically reserved for the most refractory cases of schizophrenia, is consistent with severe impairment and grave disability.  The current medical evidence supports residential treatment in this clinical setting.  In the absence of the disputed service, the patient would experience unnecessary morbidity, and require frequent treatment at the acute level of care.  The requested services are reasonably expected to optimize his functionality and prevent a more serious episode of illness.  Further, the services are safe, appropriate and consistent with good medical practice.  Based on the data provided and considering the relevant peer-reviewed literature and community practice standards, the requested residential treatment services are medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) infusions with Privigen 50 grams administered over two days monthly for three months. This patient is status post kidney transplantation with rising serum creatinine in the setting of rising BK viremia (BKV) without clinical diagnosis of rejection. In the medical literature, reported on a study evaluating the safety and efficacy of IVIG in the treatment of patients with persistent BKV and BK virus-associated nephropathy (BKVN) following renal transplant. The authors found that IVIG administration appeared to be safe and effective in treating BKV viremia and BKVN and preventing graft loss in patients who had inadequate response to immunosuppression reduction and leflunomide therapy. Based on current data, IVIG is the standard of care as a first-line therapy for BKVN that can result in allograft failure. Given this support, the requested IVIG infusions with Privigen 50 grams administered over two days monthly for three months 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 nephrology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fecal laboratory testing (CPT 82710 and 83520) provided by Quest Diagnostics Massachusetts. Findings:  The physician reviewer found that Kearon and colleagues report that when antiphospholipid antibodies are assayed, they may antibodies directed at phospholipid epitopes, which may be useful for the evaluation of patients with a strong clinical suspicion for antiphospholipid syndrome (APS) who have tested negative using other tests for APS. The records submitted for review provide insufficient clinical suspicion of APS or of exocrine pancreatic insufficiency (EPI) for a quantitative fecal fat analysis to be appropriate. In this case, the services at issue were not standard of care and did not provide additional benefits over a standard evaluation of the patients symptoms related to irritable bowel syndrome including a complete blood count, celiac disease serology, stool testing for giardia, and testing for fecal calprotectin. Therefore, fecal laboratory testing (CPT 82710 and 83520) provided by Quest Diagnostics Massachusetts was not likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the fecal laboratory testing (CPT 82710 and 83520) provided by Quest Diagnostics Massachusetts at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the residential behavior health services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). The patient was at significant risk of harm (score 3) with a history of self-harm by cutting and history of suicide attempt. The patient has a history of self-harm by cutting. The patient will have intermittent, passive suicidal ideation which will typically come during episodes of distress. The patient demonstrated moderate functional impairment (score 3) as her school work has been less than satisfactory due to the patients behavioral health issues. She reports that she socially isolates with the exception of her boyfriend and her parents. The patient has a significant co-morbidities including cannabis use disorder, major depressive disorder, anxiety disorder with panic attacks, and binge eating disorder (score 3), but does not have any medical problems which require 24-hour monitoring. The patients recovery environment is mildly stressful (score 2) and her environmental support is overall supportive (score 2). The patients response to treatment has been equivocal (score 3) given her prior outpatient treatment with a limited response. The patient has been constructive in treatment (score 2) given her level of cooperation and friendliness with staff. These findings give this patient a composite score of 18, which meets the criteria for an intensive outpatient program (IOP). The patient continued to need treatment for her depression, anxiety, and substance use, but this could have been done in a less restrictive environment. Accordingly, the residential behavior health services provided were not and are not medically necessary for treatment of this patients medical condition. 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.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 with sub-specialty 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:  An enrollee has requested intensive outpatient program (IOP) services for treatment of her panic disorder with agoraphobia and obsessive compulsive disorder (OCD).   The physician reviewer found that this patient evidenced dramatic symptoms of anxiety and affective illness with elements of character pathology. Her formidable symptom burden, which had required treatment in more restrictive settings and had not responded to outpatient services and was complicated by relationship distress and obesity. As such, a conservative treatment course was to be expected. However, based on the medical records, treatment at the IOP of care was only necessary initially.  The patient remained depressed, withdrawn and anxious. She struggled with identity issues and was having difficulty with cognitive restructuring. The patient continued with clinical interventions delivered in accordance with a treatment plan that were reasonably expected to improve her condition and prevent a more serious episode of illness. Further, the IOP services helped clarify diagnoses as evidence for borderline personality disorder emerged during the disputed treatment course and eventually prompted redirection of the therapeutic interventions. Subsequently, the patients lability, attachment issues and treatment needs no longer required treatment at the IOP level of care. Thus, the IOP services initially were medically necessary, but subsequent services were not medically necessary. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for hyperbaric therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees chronic non-healing radiation induced wound and osteomyelitis of scalp bone.Findings: There is sufficient support in the medical literature and in the submitted documentation for the requested services in this clinical setting. There is significant evidence to support the use of hyperbaric therapy for radiation induced osteonecrosis and chronic refractory osteomyelitis. In addition, the Centers for Medicare and Medicaid Services guidelines support its use in individuals who have been diagnosed with radiation induced skin injury. This patient was seen by various disciplines and had undergone graft treatments. The records indicate that this patient, who has been diagnosed with radiation induced skin injury with osteomyelitis, was unresponsive to multiple modalities. Therefore, in this patients case, where they have tried several standard wound treatments, hyperbaric services as an adjunctive therapy would be medically indicated. As such, hyperbaric therapy services have been demonstrated as medically necessary for treatment of this 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 internal medicine with expertise in wound care 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 49-year-old female enrollee has requested IV Rocephin for the treatment of her stated condition of Lyme disease. Findings:  The physician reviewer found that there is no historical evidence (i.e. a tick bite history or typical rash) of Lyme disease. The patients symptoms are all non-specific. Serological testing has been negative. Evaluation by a member of the UCSF infectious diseases faculty concluded that the patient had never had Lyme disease. Therefore, an antibiotic (either oral or parenteral) is not medically indicated to treat this patient.