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

The parent of a 15-year-old female has requested coverage for inpatient psychiatric hospital services provided over a 12-day period and coverage for residential treatment services.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions is a challenging endeavor.  As noted by the American Academy of Child and Adolescent Psychiatry, the decision regarding the appropriate level of care should primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, adherence to treatment, and family environment.  The documentation provided does not support the need for treatment in the acute setting as of the first date in question.  However, as of that date, residential treatment was medically indicated.  Due to the patients history, current status, home environment, and social bullying, there is an imminent risk that these severe psychosocial stressors will produce enough distress to undermine treatment in a level of care lower than residential.  A disposition to partial hospitalization would result in undue morbidity.  This patient continues to struggle with poor self-esteem, impulsivity, and affective dysregulation.  Residential treatment offers the best chance to help this patient consolidate the treatment gains necessary to empower her to succeed in the community.  In sum, inpatient psychiatric hospital services provided during the 12-day period in question were not medically necessary.  However, residential treatment services were and are medically necessary from that first date and forward.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lumbar spine computed tomography (CT) scan. The American College of Radiology (ACR) Appropriateness Criteria note that CT of the lumbar spine may be appropriate for acute, subacute, or chronic lower back pain or radiculopathy if the patient is a surgical or interventional candidate with persistent or progressive symptoms during or following six weeks of conservative management, or if the patient has a history of prior lumbar surgery and new or progressing symptoms or clinical findings, and magnetic resonance imaging (MRI) is contraindicated, unavailable, or nondiagnostic. In this case, the patient is status post multiple spinal surgeries, and has failed to improve with activity modification, medications, sacroiliac joint injection, and home exercise. He has progressively worsening severe lower back, buttock, and sciatic pain that are limiting his activities of daily living. Clinical examination findings are consistent with right sacroiliac joint pain and dysfunction. The documentation does not reflect focal neurologic deficits. Given that a MRI is standard of care, and there is no documentation showing that a MRI is contraindicated or would be nondiagnostic, the requested service is not medically indicated. Therefore, a lumbar spine CT scan is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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

A 48-year-old male enrollee has requested Yttrium-90 microsphere brachytherapy/selective internal radiation therapy for treatment of his metastatic pancreatic neuroendocrine carcinoma.Findings:  Three physician reviewers found that per current National Comprehensive Cancer Network guidelines for neuroendocrine tumors metastatic to the liver, for patients deemed unresectable, hepatic regional therapy (arterial embolization, chemoembolization, radioembolization), or local ablative treatment, including radiofrequency, microwave, and cryotherapy, are viable treatment options.  Given that this patient has been treated with Xeloda and Temodar, together with localized pancreatic radiation therapy and hepatic artery embolization, and given that the only residual disease is the one focus in the liver that is deemed unresectable, selective internal radiation therapy certainly was appropriate per current National Comprehensive Cancer Network guidelines. In this patients case, Yttrium-90 microsphere brachytherapy/selective internal radiation therapy was likely to have been the most beneficial treatment option.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested total knee replacement for treatment of his medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has had consistent, careful, conservative management. Standing films are stated to show normal alignment. There is no documentation the patient has trialed a medial unloader brace. Also, there is no documentation of the use of walking aides, cane, unilateral crutch, or bilateral crutch. There is no documentation of the possible use of mechanical transportation aides such as a scooter. Moreover, the longevity of ceramic bearing surfaces in the hip and the knee do not extend to beyond clinical studies of two years duration. In this case, the patients age exposes him to long term complications of an increased revision rate. For the reasons provided above, the medical necessity for total knee replacement has not been established. 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: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested for skilled nursing facility services for treatment of her cognitive deficits. Findings:  The physician reviewer found that the patient did not require skilled nursing care, and any additional services could have been provided safely at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for brain Magnetic Resonance Angiography (MRA). The submitted documentation does not support the medical necessity of the brain Magnetic Resonance Angiography (MRA) in issue. Colleagues, through a process of literature review and consensus, have recommended that neuroimaging is not indicated in migraine with a normal neurologic examination and no significant change in symptoms. This includes CT, MRI, and MRA. There are guidelines from the American Academy of Neurology which support this guideline. MR angiography is used when there is a concern for a vascular lesion such as an aneurysm or arteriovenous malformation and is not typically ordered for primary headache disorders. The records provided give no rationale for obtaining neuroimaging, as the patients migraines appear to be long standing and well controlled with Elavil. This patient fails to provide any medical evidence for needing brain Magnetic Resonance Angiography (MRA). Therefore, the services in issue were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services in issue were 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 neurology 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 advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  Three physician reviewers found that based on the records provided, the patient has a history of increased cardiovascular risk and known vascular disease. In this circumstance aggressive risk factor modification including highest tolerable -statin dose is indicated regardless of results on advanced lipoprotein testing. Guidelines for the management of cardiac risk and dyslipidemia are available and endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including Lp-PLA2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), CRP, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. 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 some 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. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with left knee osteoarthritis. Magnetic resonance imaging (MRI) of the left knee revealed moderate thinning and fraying of the patellofemoral articular cartilage. On 2/4/19, the patient reported anteromedial knee pain. The patient received left knee Orthovisc injections. In an undated letter, the patient reported being treated with seven knee surgeries and prior viscosupplementation injections provided her with five to six months of pain relief. The patient has requested authorization and coverage for Orthovisc injections in the left knee (J7324). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the left knee (J7324) are 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. 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 lasting benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports requested services in this clinical setting. Therefore, Orthovisc injections in the left knee (J7324) 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 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 of Epclusa 400mg/100mg, one tablet daily for 12 weeks.Findings:  The physician reviewer found that according to the recent 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 should be treated except those with limited life expectancy due to non-liver related conditions. Per the guidelines, Epclusa is recommended as first-line for treatment-naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin.  Delay in treatment may result in decreased survival. 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 sub-specialty 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: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) of thyroid nodule. The records provided for review document that this patient presented with a thyroid nodule. Fine needle aspiration (FNA) biopsy demonstrated results consistent with a benign nodule. The patient is noted to have symptoms including weight loss, palpitations, and hot flashes, as well as compressive symptoms such as pain and constriction in the neck. The patients provider has recommended treatment with RFA. Subclinical hyperthyroidism is defined by a low or undetectable serum thyroid-stimulating hormone level, with normal free thyroxine and total or free triiodothyronine levels. As in this patients circumstance, the autonomously functioning thyroid nodule, if untreated, it can lead to potential health risks and impaired quality of life (Donangelo and Suh). Since RFA is less invasive than surgery, the procedure has been gaining popularity for treatment of thyroid nodules. Published studies suggest that RFA has an excellent safety profile compared to existing management strategies (Muhammad, et al.). In addition, recent data suggest that RFA has good efficacy and safety in the treatment of autonomously functioning thyroid nodules (Kim, et al.). Given this support, the requested RFA of thyroid nodule is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested RFA of thyroid nodule 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services that were received at a time when the enrollee was under 18 years of age.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for a child or adolescent needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 4, which corresponds with a serious risk of harm. This is due to documented suicidal ideation. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to the patient having been unable to go to school in the period preceding her admission to the residential treatment center. In terms of comorbidity, the records support a score of 4, which corresponds with major comorbidity, due to the patients major depressive disorder and generalized anxiety disorder. With regards to level of stress of the recovery environment, the records support a score of 3. The patients recovery environment was moderately stressful. In terms of level of support of the recovery environment, the records support a score of 3, which reflects limited support in the environment, as the patients mother was supportive. With regards to resiliency and treatment history, the records support a score of 4. The patients score reflects that the patient was not able to maintain a stable mood despite therapy for some years. In terms of acceptance and engagement of the patient and her parents, the records support a score of 3. This score reflects that the patients parents were not both accepting of the patients mental health treatment. Thus, the patient had a composite score of 24. This score correlates with a treatment intensity level of care of Level Five, or Medically Monitored Residence Based Services.In this case, given the severity of the patients illness, which involved a risk of harm associated with the patients long history of intermittent suicidal ideation, a residential treatment center level of care was clinically appropriate for the patient. Accordingly, residential treatment center services were medically necessary to treat the patients medical condition.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: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for use of a power wheelchair with tilt option (GRP 2).The submitted documentation does not establish that the patient has upper body musculoskeletal, cardiovascular, respiratory or other impairments that would preclude effective propulsion of an optimally configured manual wheelchair for accomplishing mobility-related activities of daily living. There are no objective indications of any pathology or other medical condition beyond a reduced subjective tolerance for propelling a manual wheelchair. This does not constitute an impairment or functional limitation with respect to this activity.The submitted records also do not establish that the patient has upper body impairments that would preclude effective pressure relief maneuvers in an appropriately fitted manual wheelchair in conjunction with an appropriate pressure relieving seat cushion. Compliance is the key to pressure injury prevention when the physical capacity to perform the appropriate maneuvers is intact. Lack of compliance can result in pressure ulcer development with or without tools such as power tilt-in-space. A study of the effects of wheelchair cushions and pressure relief maneuvers on ischial interface pressure and blood flow in people with spinal cord injury. They found that regardless of the cushion being used, pressure relief maneuvers resulted in very large reductions in interface pressures and significant increases in buttock blood flow. Poor subjective tolerance of or compliance with performing pressure relieving maneuvers does not constitute an impairment or functional limitation with respect to this activity.The patients most recently documented mobility evaluation is a physical therapy evaluation that indicated that the patient has the physical capacity to propel a manual wheelchair and to perform adequate pressure relieving maneuvers using his own body power. No impairment precluding these functional activities and tasks was noted on this evaluation. Under these circumstances, the requested use of a power wheelchair with tilt option (GRP 2) is not medically necessary for the patient to perform one or more mobility related Activities of Daily Living or Instrumental Activities of Daily Living in or out of the home, including access to the community.