Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a water circulating cold pad with pump (HCPCS E0218). The Health Plan has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees symptoms related to his spine surgery. Findings The submitted documentation fails to demonstrate the superior efficacy of the device at issue in this clinical setting. There is a lack of recognized evidence based medical guidelines to support the use of water circulating cold pad with pump as an option for treatment of acute low back pain over the standard ice/cold packs. This patient underwent lumbar spinal surgery on 3/13/18 and was prescribed a cold compression unit for a three week post-operative use. The device at issue was prescribed pre-operatively. As of 3/19/18, the pain had no swelling and was managing his residual back pain without narcotics. The patient stated that plain ice packs were not enough, but there is no clear indication from the submitted records that he had tried standard cold packs in the post-operative period at issue or that they had failed to provide pain reduction. There is no compelling rationale presented or extenuating circumstances noted to support the superiority of a water circulating cold pad with pump over standard cold/ice packs for treatment of this patient, post-operatively. Therefore, the requested water circulating cold pad with pump for dates of service 3/15/18 through 3/28/18 was not likely to have been of greater benefit for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined the device 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 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: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested inpatient treatment and continued inpatient treatment for treatment of her bulimia nervosa, purging type, major depressive disorder, and post-traumatic stress disorder.   Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Upon admission, the patient had conservative precautions and an aggressive medical work-up including vital sign monitoring, daily physical examination and serial laboratory analysis.  By the date indicated, the patient had achieved the original goals of the admission.  She was normotensive with a normal electrocardiogram.  Her laboratory values were normal, and she had gained weight.  Neither imaging nor further medical work-up was indicated.  Psychiatrically, the patient was stable on her serotonergic enhancing medication.  She was not psychotic, cognitively impaired, suicidal or homicidal.  Per the peer-reviewed literature and the American Psychiatric Association, the optimal treatment setting for bulimia is outpatient based services.  All told, inpatient treatment was not medically necessary.  Additionally, the medical records do not support the medical necessity of continued inpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for in-home occupational therapy services. Young patients with Dravet syndrome have been found to develop intellectual disabilities over time. Additionally, they have behavioral, sleep, and psychological issues that are problematic. These issues prevent with delays or inability to meet expected milestones in different domains of development. As a result, multidisciplinary team involvement including physical, occupational and speech therapies, is essential to maximize the quality of life and well-being for patients with Dravet syndrome and their family. Acquisition of effective motor skills is relevant for activities of daily living (ADLs) including communication and learning, social interaction, and self-care activities. Functional impairments can limit a patients ability to participate in age appropriate and meaningful activities of childhood. Occupational therapy is the discipline that trains children to effectively interact with their environment and engage in desired daily activities. In this patients case, occupational therapy is appropriate to maximize functional independence and participation in school, home, and community activities. The patients severe developmental limitations compromise his independence and participation in basic ADLs. Given these findings, the requested in-home occupational therapy services are medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine 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 six-year-old female enrollee has requested inpatient treatment at a neuropsychiatric hospital for the treatment of the enrollees psychosis, not otherwise specified.  Findings:  The physician reviewer found that this patient presents with complex symptomatology. There is limited documentation of an evaluative child psychiatry workup. At the present time, it is not safe to transfer this patient home. She presents a danger to others, especially her sibling. She remains severely disturbed and continues to possibly be psychotic. There is a real and compelling danger that she will decompensate further without continued care and proper supervision. Accordingly, the patient should remain in an acute inpatient psychiatric hospital until an appropriate less restrictive setting is found. Until the patient is able to be transferred to an appropriate less intensive level of care, evaluation and titration of medications should be continued as an inpatient, under the direction of a child and adolescent psychopharmacologist and psychiatrist, if possible.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male enrollee has requested Protopic 0.1% for the treatment of the enrollees condition. Findings:  The physician reviewer found that the submitted evidence does not establish that Protopic 0.1% is medically necessary. Based on the evidence provided, it is unclear whether Protopic ointment 0.03% has been used on the patient and if so, for how long. If Protopic ointment 0.03% has been used for three months or more with little to no improvement, then Protopic ointment 0.1% would be medically necessary. If Protopic ointment 0.03% has not been used, or used for less than three months, then the patient should undergo a three-month trial of Protopic ointment 0.03%. If the patients treating provider documents little to no improvement, the treatment should be switched to 0.1%.  However, because there is no evidence in the medical record that there has been a trial and failure of Protopic ointment 0.03% for at least three months, there is no medical necessity for a trial of Protopic ointment 0.1% at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested hydrocodone 5 mg/acetaminophen 325 mg #30 for medical treatment of her chronic pain syndrome, acquired kyphosis, and acquired spondylolisthesis.   Findings:  The physician reviewer found that the patient was encouraged to attend physical medicine and rehabilitation by her primary treating provider. In addition, she has been on hydrocodone long-term without documentation of improved function or attempted weaning. Further, the records indicate that the patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  Thus, it is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. All told, the requested hydrocodone 5 mg/acetaminophen 325 mg #30 is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested elbow manipulation under for treatment of his medical condition. Findings:  Two physician reviewers found that there is a lack of large volume, long-term peer-reviewed outcome studies to support the elbow manipulation under anesthesia for treatment of the patients medical condition. Araghi and colleagues performed a study of 51 consecutive patients who underwent elbow examination under anesthesia. The authors concluded that examination (manipulation) under anesthesia can be a valuable adjunctive procedure to help regain the elbow motion obtained at the time of surgical release. Because this was not a controlled series, the authors opined that additional studies might be conducted to refine those not benefiting from this procedure. In this case, the patient sustained a dislocated radial head fracture with ligament disruption. He underwent open reduction and internal fixation. He was diagnosed with a healed fracture with loss of range of motion. Fluoroscopic examination documented a protruding screw that appeared to block left elbow rotation. Screw removal was recommended and performed along with capsular release and manipulation under anesthesia. There is a lack of compelling rationale presented supporting the manipulation under anesthesia over capsular release and standard post-operative physical therapy following screw removal to regain range of motion. Therefore, the elbow manipulation under anesthesia was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee has requested resumption of partial hospitalization level of care with a cap of 20 hours per week for treatment of her major depression. Findings:  The physician reviewer found that the submitted medical records support the requested services in this patients case.  This patient has been hospitalized twice in the past three months.  She is not stable on a psychotropic medication regimen.  The patient did well at partial hospitalization program level of care, but deteriorated in a less restrictive setting.  This is suggestive of a failed consolidation of treatment gains.  Considering the patients disease burden and clinical history, partial hospitalization program services will likely reduce the likelihood of another acute psychiatric admission.  The current medical evidence supports the requested services in this clinical setting.  All told, resumption of partial hospital programming with a cap of 20 hours per week is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old morbidly obese female within the range of super morbid obesity. She has multiple comorbidities and has failed medical management. The patient has obtained psychiatric clearance for weight loss surgery. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied her request on the basis that the duodenal switch procedure is not medically necessary for treatment of her medical condition.The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for the use of a continuous passive motion (CPM) machine and cold compression unit for treatment of her post-op (total knee replacement) left knee condition. Findings:  The physician reviewer found that there is no significant increase in range of motion in the long-term from the use of a CPM machine following uni-compartmental knee arthroplasty. Objective evidence that CPM results in improved clinical outcomes is lacking at this time. There is no literature to substantiate the need for continuous passive motion in the uni-compartmental knee arthroplasty perioperative period.  There is no peer-reviewed literature that suggests that this is more advantageous than standard available treatment (i.e., ice wraps/packs with ace bandage for compression) in the perioperative period.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy surgery (CPT code 15830). The medical records do not include documentation of any supervised physician treatment of rashes, yeast infections, or bacterial infections underneath the pannus. The provider reported that the patient has a history of vaginal yeast infections treated with oral fluconazole. Based on the available records, there is insufficient evidence of recurrent rashes and infections unrelieved by conservative medical therapy directed at the fold underneath the pannus. Additionally, the photographs do not demonstrate a recurrent rash. There is also no documentation of any functional disability related to the abdominal pannus, and no documentation that the patient has maintained a stable weight. Given these findings, the requested panniculectomy surgery (CPT code 15830) is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. This patients condition does not constitute an abnormal structure of the body. The appearance of the body is normal for someone who has gained and lost a significant amount of weight. The requested surgery could be considered to improve function if there are documented rashes underneath the pannus causing functional issues with activities of daily living, and these rashes are not managed with conservative medical therapy. In this case, there is a lack of documentation of medically supervised treatment of the rashes. Although there is one note documenting the use of nystatin powder, there are no prescriptions noted for any antifungal medications or antibiotics to treat issues related to the pannus. Moreover, the records do not report any rashes that have persisted despite adequate therapy. Therefore, the requested panniculectomy surgery (CPT code 15830) is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ensure three times per day. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested product.  Weight loss in patients with human immunodeficiency (HIV) infection is usually episodic, occurring with secondary infections or gastrointestinal diseases.  Patients with anorexia-cachexia syndrome who are able to eat should be recommended to have small, frequent meals that are dense in calories.  In this case, the documentation does not support that the patient has had a clinically significant loss of weight.  The office note documented that the patients HIV infection was well-controlled.  There is no documentation of any secondary infections.  The patient does have a laryngeal prosthesis with persistent fistula and dysphagia.  The documentation does not indicate the patient has failed treatment with alternative food consistencies or has had a loss of appetite. Final Result: The reviewer determined that the requested product 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 internal medicine 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 patient is a four-year-old male with a diagnosis of autism who has been receiving speech therapy to treat the issues of delayed receptive language skills, social skills, and pragmatic speech. The patient has undergone developmental assessment including applied behavioral analysis evaluation, Rosetti Infant-Toddler Language Scale, and the Preschool Language Scale 4th Edition. He had difficulty completing the standardized testing. The informed testing and observation are the primary tools used to evaluate progress. The patients parents have requested coverage for continuation of the patients speech therapy. The Health Plan has denied the request on the basis that speech therapy is not medically necessary for treatment of the patients condition. The diagnosis of autism does not appear to be in dispute and based upon the evaluation of the child neurologist and psychologist, the patients diagnosis is substantiated. It is not uncommon for preschool age children with moderate to severe autism to be incapable of completing standardized testing. Many of the tests are not valid in children without autism until age three. In addition, the goals set in speech therapy typically are not on a linear scale as is seen with a physical scale such as the FIM or WeeFIM. Gains in autism can fluctuate and thus trends rather than discrete trial progress need to be followed. This is more a failure of the medical communitys understanding of autism and the poor quality of tools that are available to measure progress than a demonstration of lack of progress. Therefore, the speech therapists documentation of progress toward the goals is sufficient evidence that the patient is progressing. Because speech therapy is considered standard of care in autistic children with receptive expressive and pragmatic speech delays and since the patient is making progress, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should undergo a reevaluation in six months to determine if progress is still being made.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested adult substance abuse inpatient acute rehabilitation services for treatment of his alcohol dependence. Findings:  The physician reviewer found that the inpatient detoxification was medically indicated for this patient. However, the submitted documentation does not establish the medical necessity for continued hospitalization in an acute setting. This patient was cooperative and engaged in treatment. There was no imminent risk of self-harm or harm to others. Furthermore, there were no major comorbidity issues. Based upon Level of Care Utilization System (LOCUS) criteria and American Psychiatric Association guidelines, this patient was a candidate for sub-acute residential treatment. Adult substance abuse inpatient acute rehabilitation services provided from the date in question were not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested the LINX procedure for treatment of his gastroesophageal reflux disease (GERD), atrophic gastritis, and esophagitis. Findings: Two physician reviewers found that based on the patients records provided for review, there is a lack of information regarding the patients treatment with proton pump inhibitor (PPI) therapy. In addition, the peer-reviewed medical literature suggests that in patients whose GERD symptoms are refractory to medical therapy, surgical intervention is available with fundoplication. There is a paucity of clinical data that LINX is superior to fundoplication. In a multicenter study, Ganz and colleagues noted a substantial rate of dysphagia as a recognized complication. Thus, until a randomized control trial with fundoplication as the comparator arm is performed, LINX is not likely to provide this patient with a superior health outcome when compared to standard available therapies.