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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a bone graft for treatment of her medical condition.   Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  The provider indicated that the patient had an existing bridge which had failed, and the treatment plan was developed for an implant to replace one of the missing teeth.  The provider reported that the bone was of inadequate height for implant placement, requiring a graft to augment the ridge in the area of the sinus.  The requested service code is used for periodontal regeneration when the periodontal disease process has led to a deformity of the bone adjacent to a tooth.  This code generally requires diagnosis of type III or type IV periodontal disease.  There is no evidence of periodontal disease present requiring this grafting procedure.  In sum, a bone graft was not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at 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 dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old female enrollee has requested occupational therapy (OT) for treatment of the enrollees developmental coordination disorder.  Findings:  The physician reviewer found that based on the information provided, there is no documented illness, injury or congenital deformity associated with the delayed motor skills. The goals as listed cannot be achieved in a reasonable amount of time and there is no end date to the therapy. In addition, the majority of the goals are educationally-based and are not medical goals. The goals listed that are not educationally-based are primarily therapeutic exercises (sustain supine flexion, perform jumping jacks, hit a balloon with a racquet, perform two pull-ups) that do not require the expertise of a licensed therapist.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) treatments provided for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that TMS is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. Despite the findings from the articles referenced in the providers appeal letter, a group of TMS proponents arrived at a different conclusion regarding duration of care. According to colleagues The standard parameter setprovided clinical benefit in treatment courses up to 6 weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The article did suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. However, based on a starting date, the patient had already received this treatment. There is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical evidence does not support a reasonable expectation that additional TMS therapy as would have improved the patients condition or prevented a more serious episode of illness.  Further, the medical records failed to demonstrate that standard psychopharmaceutical strategies and non-pharmacologic interventions had been exhausted in this case. Thus, TMS services in dispute were not medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for bilateral custom arch support orthotics. A pediatrician saw the enrollee for pain in his feet for which he has tried different shoes. The pediatrician prescribed custom arch support orthotics. There is insufficient evidence in the medical record of radiographs or imaging results, so the degree of deformity is unknown. The enrollee was advised to wear arch supports and return if they failed to improve his symptoms. According to the medical literature, in enrollees with painful juvenile flexible flat feet, generic foot orthoses are sufficient, unless the enrollee presents with juvenile arthritis. Many different foot conditions can occur in the juvenile population, so it is imperative to determine the underlying cause of the foot pain prior to ordering custom orthotics. In cases of flatfoot deformity in the presence of chronic juvenile arthritis, very few studies show that the pain is reduced with the use of functional custom orthotics. Finally, there is insufficient documentation in the record of the prior use of over-the-counter orthotics that failed at symptom relief for this enrollee.  Studies have shown there is no benefit to custom orthotics over the generic orthotics, in these cases. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a wearable cardioverter defibrillator.Findings: Two of the three physician reviewers found that a wearable cardioverter defibrillator is indicated under these circumstances. The patient had a recent myocardial infarction complicated by transient shock and now has a significantly reduced ejection fraction. The patient does not have an initial indication for an implantable defibrillator since they are less than 40 days since acute myocardial infarction and less than 3 months since PCI. A wearable cardioverter defibrillator can provide temporary protection from early sudden death due to arrhythmia in this patient population during this interim period. Although no randomized controlled prospective trials have been completed yet, this short-term indication for wearable defibrillator therapy has support. This support can be seen in large published case series literature, in a published longer term prospective registry, along with expert opinion and a AHA Scientific Advisory. Therefore, under these circumstances, a wearable cardioverter defibrillator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested device is 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:  One reviewer is board certified in internal medicine, with subspecialty certificates in cardiovascular disease and interventional cardiology, and is actively practicing. One Reviewer is board certified in internal medicine, with a subspecialty certificate in cardiovascular disease, and is actively practicing. One Reviewer is board certified in internal medicine, with a subspecialty certificate in cardiovascular disease, 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

A 44-year-old female enrollee has requested coverage for artificial disc replacement surgery.  Findings:  Three physician reviewers found that the medical records for this patient note neck pain and cervical radiculopathy and weakness in the C6 nerve root, with biceps and wrist extension weakness.  The provider noted that MRI was consistent with single-level pathology at C5-6 with disc herniation.  In this patients case, the superior effectiveness of the requested artificial disc replacement surgery has not been established.  There is a lack of long-term evidence in the peer-reviewed literature concluding the superiority of cervical arthroplasty over fusion in terms of efficacy and safety.   At this time, randomized controlled trials involve short-term to intermediate-term follow-up.  The most touted advantage of arthroplasty over fusion, reduction of adjacent-level degeneration, has not been validated in randomized controlled trials to date.  Long-term adverse effects of arthroplasty materials, particularly polymer and metallic debris, are not known at this time.  In sum, the requested procedure is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional eight hours of neuropsychological testing (CPT 96133 - 4 units and CPT 96139 - 8 units), for a total of 27 hours of testing. The diagnosis of attention deficit hyperactivity disorder (ADHD) is based on upon clinical evaluation. The American Academy of Pediatrics guidelines for the diagnosis and treatment of ADHD recommends, To make a diagnosis of ADHD, the primary care clinician (PCC) should determine that Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria have been met, including documentation of symptoms and impairment in more than one major setting (i.e., social, academic, or occupational), with information obtained primarily from reports from parents or guardians, teachers, other school personnel, and mental health clinicians who are involved in the child or adolescents care. The PCC should also rule out any alternative cause. In this case, the patient has been approved for 19 hours for neuropsychological testing to include the Connors Continuous Performance Test 3 (CPT 3) and Connors Continuous Auditory Test of Attention (CATA), as well as the Behavior Assessment System for Children 3 (BASC-3). These tests are supplementary and not fundamental to the diagnosis of ADHD. Per the reviewers calculations based on a review of test publishers websites, the proposed list of tests does not require more than 19 hours of testing, which includes administration, scoring, and reporting time. Medical documentation does not substantiate additional testing needs or rationale for additional time. Therefore, an additional eight hours of neuropsychological testing (CPT 96133 - 4 units and CPT 96139 - 8 units), for a total of 27 hours of testing are not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Case Summary An enrollee has been diagnosed with post-traumatic stress disorder (PTSD). The patient was reportedly experiencing problems coping with occupational stress. Crisis services were reiterated and the patient refused any new medication. Notes submitted through the visit date indicated that the patient is being treated with therapy twice weekly and is in a Seeking Safety group that is helpful. The enrollee has also signed up for an anger management class. The Health Plan has denied coverage for the requested individual therapy sessions.MD Analysis: In this case, one-hour individual therapy sessions three times a week are medically necessary to address this patients behavioral health issues. Applying the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS), the patient meets the criteria for one-hour individual therapy sessions three times per week. In terms of risk of harm, the records support a score of 2. With regards to functional status, the records support a score of 2 moderate. This is due to conflict with peers and quitting their job. Medical, addictive and psychiatric comorbidity, the records support a score of 2. This is due to overall medical stability with some mental health issues that are under control. In the terms of recovery environment, level of stress of the patients recovery environment, the records support a score of 3. This is due to a stable living environment but conflict with peers. With regard to recovery environment, level of support, treatment and recovery history, the records support a score of 3. This is due to mention in the records of problems with a roommate that contribute to her symptoms. For treatment and recovery history, the records support a score of 3. This is due to minimal past treatment response. In terms of engagement and recovery status, the records support a score of 3. This is due to fair cooperation in treatment, but failing to use available treatment resources. This gives the patients presentation a composite score of 18, which supports intensive outpatient services at a minimum of three days per week and are medically necessary. Final Result: The reviewer determined that the IOP 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 30-year-old male has requested authorization and coverage for balloon dilation Eustachian tuboplast for treatment of the enrollees Eustachian tube dysfunction. Findings:  The physician reviewer found that Eustachian tube dysfunction (ETD) is a disorder for which there are limited medical and surgical treatments. Eustachian tube balloon dilation has been shown to be a safe intervention, which may have a positive effect on objective and subjective indicators for chronic dilatory ETD in adult patients. A prospective, multicenter, randomized, controlled study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter versus continued medical management alone to treat Eustachian tube dilatory dysfunction in adults. Therefore, in this patient with chronic ear disease and ETD, who is status post treatment with tympanostomy tubes and medical therapy, balloon dilation Eustachian tuboplasty (CPT Code 69799) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One physician reviewer found that the literature shows that there are signs of normalization of tympanograms after balloon dilation of the Eustachian tube (ET) but there is no evidence of long-term effects.Final Result: The reviewers determined that the requested procedure is 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient has failed clobetasol solution, Dovonex ointment and Diprolene for treatment of plaque psoriasis. She has also failed natural sunlight exposure. However, there is no documentation demonstrating that the patient has tried and failed one of the Plans preferred therapies. Given that there is no documented intolerance, contraindication or lack of efficacy to the formulary preferred drugs, the request for coverage of Otezla is not medically necessary for treatment of the patients plaque psoriasis. 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 dermatology 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 45-year-old male has requested past and future coverage for partial hospitalization program (PHP) services provided for treatment of his multiple mental health conditions.  Findings:  The physician reviewer found that in this case, the patients symptoms failed to meet published guideline criteria for partial hospitalization program (PHP) level of care services for the dates at issue. Specifically, the patient does seem to have insight into the severity of his drug and alcohol problem and has the ability to develop coping skills to deal with this problem.  During the time frame at issue the patient was on medication that was helping him control his cravings for alcohol. Additionally, he did not have any intervening medical or psychiatric event that was serious enough to interrupt his rehabilitation. Although he does have MDD and PTSD, these are being treated, and the patients treating psychiatrist lists his MDD as being in partial remission.  Thus, the patient failed to meet established mental health care guideline criteria for PHP services beginning on the date at issue.
Appeal type: Urgent Care
Decision: Upheld

The parent of a nine-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that this patient presented to the Emergency Department with a fever, cough and sore throat. Upon arrival to the Emergency Department, his vital signs were normal. His temperature was 99.3. The medical records note that the patient appeared happy, playful and smiling. The patient had received antipyretics nine hours prior to admission. Physical examination revealed breath sounds were clear and equal bilaterally. Flu swab was positive for influenza A, and the patient was discharged on Tamiflu in stable condition. An emergency medical condition is defined as a medical condition which manifests itself by acute symptoms of sufficient severity, including pain, such that the absence of immediate medical attention would reasonably be expected to result in placing the patients health in serious jeopardy, or causing serious impairment to bodily functions or serious dysfunction of any bodily organ or part. There is no documentation in the submitted medical records that the patients condition met this definition. The patient was in stable condition on arrival to the Emergency Department and did not exhibit any signs or symptoms of serious illness. He did not have a high fever, cold sweats or convulsions while in the Emergency Department. He was noted to be in no acute distress and appeared well. The patients symptoms upon presentation were not such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize the patients health in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested Namenda for treatment of her chronic migraines.  Findings:  Three physician reviewers found that Namenda has not been approved by the Food and Drug Administration (FDA) for the use of migraine headache. Thus, its use in this case would be off-label. Namenda is indicated and FDA approved for the treatment of neuronal degeneration and Alzheimers disease. A review of the relevant scientific data confirms that Namenda is not supported in the clinical studies as safe and effective for treatment of migraine headache. The publications referenced above suggest that Namenda has been researched as a treatment for chronic tension-type headaches, but the retrospective and observational studies have methodological flaws that prevent their findings from establishing Namenda as a proven treatment modality for this indication. This patients condition is likely exacerbated by her coincidental status post surgical fusion at C5-6 with myofascial neck pain and right shoulder pain. There is insufficient documentation in her records of failure or intolerance to standard treatments that have been the subject of randomized, controlled, blinded trials, and are FDA approved for the treatment of migraine headache. Thus, the use of Namenda for this patients condition would be investigational in this clinical setting.