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

The parent of a 16-year-old female enrollee has requested continued residential treatment care for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that this patients eating behaviors could not be adequately controlled outside of a 24/7 residential facility such as the one to which she had been admitted. Although not well documented, it appears that the patient had received prior outpatient care from both a psychiatrist and therapist. While she was reasonably stable medically, there were orthostatic issues and laboratory values of concern. She was clinically depressed and had just begun to voice suicidal thoughts. It would be unsafe and not prudent to treat this patient outside of a residential facility. This patients condition requires residential care. The continuing need for such care should be reviewed at least monthly.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested reimbursement for physical therapy (PT) for treatment of his before and after right knee surgery. Findings:  The physician reviewer found that The patient had surgery for right ACL reconstruction and right MCL repair. He resumed PT postoperatively. His right knee range of motion (ROM) had decreased to 0 to 60 degrees, he was unable to do household chores and car transfers were difficult. It was medically appropriate to resume therapy at that time. The patients ROM was 0 to 95 degrees, he could perform car transfers and was able to ambulate without an assistive device (although he still had pain). His right knee ROM was 112 degrees in flexion, strength was 4/5, he had minimal pain with gait and was full-weight bearing on the right lower extremity.  The patient appears to have followed a prescribed exercise plan, which could have been done in a home program. The record also indicates he was no longer using his cane to assist with ambulation.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested  acupuncture for treatment of her insomnia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The medical records document ongoing insomnia since the patient was 22 years old.  There is sufficient support for acupuncture in this clinical setting.  Cao and colleagues noted that acupuncture can be effective for the treatment of insomnia.  Additionally, Huang and colleagues noted that acupuncture showed positive effects in terms of improving various aspects of sleep.  In this patients case, the records document prior medication trials which were discontinued due to either intolerance or inefficacy.  Therefore, the requested acupuncture is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral brachioplasty. According to the American Society of Plastic Surgeons (ASPS) criteria for the surgical treatment of skin redundancy for obese and massive weight loss patients, only in rare circumstances are buttock, thigh, or arm lifts needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature. In this case, the records noted massive weight loss following bariatric surgery. Notes reported that the patients highest weight was 294 pounds, and that her present weight was 151 pounds. The patient has redundant skin on her upper arms. She reports a recurrent rash underneath her arms, however, despite being requested, the submitted records did not show documentation of appropriate medical treatment of the rash or of failure of appropriate medical treatment of the rash. The patient does not have a functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. Photographs submitted by the patient of the upper arms show widespread erythema, lichenification, and scaling characteristic of a dermatologic skin problem, not intertrigo. Therefore, bilateral brachioplasty is not medically necessary for the 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; (2) to create a normal appearance, to the extent possible. In this case, the patient has lax skin on her upper arms that is an expected result of the gain and loss of weight and is not an abnormal structure of the body. The patient has an untreated skin rash that is not intertrigo, and is not an abnormal structure of the body. Thus, bilateral brachioplasty is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is 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: The patients parent has requested authorization and coverage for 30 sessions of transcranial magnetic stimulation (TMS), or a lesser amount of TMS services. Based on the current available data and U.S. Food and Drug Administration (FDA) approval, controlled clinical trials have not demonstrated that NeuroStar TMS therapy is safe and effective in patients younger than 22 years of age. In a recent review, Croarkin and colleagues concluded that there is a paucity of systematic data demonstrating the safety of TMS in children and adolescents. In this case, the patient has experienced long-term, debilitating symptoms that have persisted despite multiple medication trials and behavioral treatments, including long-term RTC level of care treatment. However, the current peer-reviewed medical literature and FDA do not support treatment with TMS given the patients age. All told, 30 sessions of TMS, or a lesser amount of TMS, are not medically necessary for treatment 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 subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female has requested BART testing for evaluation of her breast cancer.   Findings:  Two physician reviewers found that the records indicate the patient has a first-degree relative, her mother, who was diagnosed with breast cancer. The provider has recommended BRCA1 and BRCA2 testing as well as BART testing for evaluation of her condition and direction with potential treatment options.  As this patient has a personal history of breast cancer and a first-degree relative who was also diagnosed with breast cancer, she meets the criteria for BRCA1 and BRCA2 testing. However, in the absence of the BRCA1 and BRCA2 test results, the utility of the requested BART testing cannot be assessed. The peer-reviewed medical literature does not support an indication for the BART test until the BRCA1 and BRCA2 test results are available for review. Therefore, the requested BART testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard approach at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male has requested  coverage for speech therapy twice per week for treatment of his speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient at the requested frequency of two, one-hour sessions per week.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested a PET scan of the brain for dementia evaluation.   Findings:  Two physician reviewers found that while PET imaging can show abnormalities within the brain in patients with dementia, the findings on PET imaging do not always contribute to the treatment planning of the patient. A review of the peer-reviewed literature revealed no significant evidence to support the use of PET imaging for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laser assisted cataract surgery and intraoperative aberrometry in both eyes.Findings:  Three physician reviewers found the use of femtosecond laser at the time of cataract surgery is well-described. However, at this time, there is a lack of conclusive evidence that this technology is indicated for uncomplicated cataract cases. In this case, there is no evidence in the records provided to indicate why the use of femtosecond laser and aberrometry were indicated for cataract extraction. The presence of glaucoma and insertion of iStent is not an indication for the use of the femtosecond laser. Thus, laser assisted cataract surgery and intraoperative aberrometry in both eyes was not likely to have been of greater benefit than other available treatment options.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Inspire upper airway stimulation system (hypoglossal nerve stimulation). Current medical literature supports the safety, efficacy, and long-term outcomes in the treatment of OSA with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea/hypopnea index (AHI), oxygen desaturation index (ODI), and Epsworth Sleepiness Scale (ESS), combined with improvements in quality-of-life scales. Researchers report that the Stimulation Treatment for Apnea Reduction (STAR) trial showed that upper airway stimulation systems provide significant improvement in sleep-related quality of life outcome measures across 48 months. Researchers note that the ADHERE registry following the outcomes of upper airway stimulation in patients who have failed CPAP therapy of OSA continued to show significant improvement in subjective and objective OSA outcomes with the use of upper airway stimulation therapy. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA as a safe and effective second-line treatment of moderate-to-severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP therapy. In this case, the requested service is likely to be more beneficial, given that the patient has already failed CPAP therapy, and the alternative, no treatment, would lead to potential harms such as increased medical comorbidities, including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. Therefore, the Inspire upper airway stimulation system (hypoglossal nerve stimulation) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Inspire upper airway stimulation system (hypoglossal nerve stimulation) 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 service 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: Physician reviewer 1 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 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: Overturned

A 68-year-old female enrollee has requested an MRI brain stem with and without contrast and an MRI of the orbit/face/neck with and without contrast to be performed at UCLA Medical Center for evaluation of her left temporal bone squamous cell carcinoma.  Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested services in this patients case.  Based upon the clinical notes, it is medically necessary that the requested services be performed at UCLA Medical Center.  While the requested scans may be performed at an in-network facility, there is no guarantee the necessary sequences and other scanning parameters used at UCLA Medical Center in the past will be utilized by the in-network facility.  In addition, the in-network interpreting radiologist will not have the host of prior studies done at UCLA Medical Center in order to conduct a detailed comparison over time, which is crucial to detect subtle changes in a complicated tumor treated previously with surgery, chemotherapy, and radiation.  All told, it is medically necessary that the requested MRI brain stem with and without contrast and the MRI of the orbit/face/neck with and without contrast be performed at UCLA Medical Center.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic lab tests (CPT codes 81225, 81226, 81227, 81231). The records provided for review document that this patient underwent pharmacogenomic testing to assess the best therapeutic regimen to address her behavioral health issues. However, the routine use of pharmacogenetic testing is not recommended in depression treatment guidelines and medical literature (Malhi, et al.; Kennedy, et al.). The Clinical Pharmacogenetics Implementation Consortium (CPIC) published guidelines supporting the use of hepatic metabolizer status genotyping in dosing various antidepressants. However, the CPIC guidelines are not based on prospective randomized controlled trials comparing genetically guided medications with unguided regimens (Hicks, et al.). Pharmacogenomic testing has the potential to decrease treatment-emergent side effects and improve treatment response, as well as decrease inpatient admissions and readmissions due to lack of efficacy or side effects. Based on current peer-reviewed medical literature, additional research is needed to establish the clinical role of pharmacogenomic testing in this clinical setting. Accordingly, the genetic lab tests (CPT codes 81225, 81226, 81227, 81231) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the genetic lab tests (CPT codes 81225, 81226, 81227, 81231) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Upheld

A 52-year-old female enrollee has requested outpatient psychotherapy, at a frequency of five sessions per week, for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the data reviewed failed to support medical necessity for continued therapy five times weekly as of the date in question. The patient has clearly shown significant improvement. However, the therapist indicates that the turn-around in the patients condition has primarily occurred since 2008 at which time her significant other attained sobriety and there is no evidence that her improvement is related to the intensive therapy as opposed to her improved social situation. Additionally, there is no Axis II diagnosis despite ample indication that the patient meets diagnostic criteria for borderline personality disorder according to American Psychiatric Association (APA) guidelines. Further, there seems to be contradictory findings in the documentation provided, in that, the outpatient treatment report submitted by the therapist on the said date indicates that the patients global assessment of functioning (GAF) score decreased from 53 to 40, which is inconsistent with the therapists assertion that the patient is able to hold a job and maintain a successful relationship. A GAF of 40 would also seem to indicate that the current treatment program is not successful. Moreover, there have been no changes in medications, suggesting that the patient has benefitted maximally and APA guidelines do not support either daily psychotherapy for individuals with borderline personality disorder or long-term psychotherapy for patients with bipolar disorder.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection (HCPCS J7325) in the right ankle.In a review by Papalia and colleagues, the authors indicate, Current evidence suggests that viscosupplementation for treatment of ankle osteoarthritis is a safe and effective method. The authors also concluded that more randomized controlled trials are needed.  Khlopas and colleagues state that viscosupplementation with hyaluronic acid has been shown to be a safe and effective method of treating osteoarthritis of the ankle. The authors reason that, For patients who have moderate to severe disease, surgery may be indicated. However, current surgical options are either associated with high rates of complications or restrict ankle range of motion (ROM). Further, the authors conclude, Early stages of the ankle osteoarthritis should be treated with [] non-surgical methods, and once the disease progresses, surgical options can be utilized. In this case, the patient has been diagnosed with severe osteoarthritis of the right ankle. The patient has tried and failed other conservative treatments. Therefore, the requested Synvisc One injection (HCPCS J7325) in the right ankle is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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.