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

Summary Reviewer 

A 67-year-old male enrollee has requested reimbursement for inpatient stay provided from 1/02/19 through 1/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The records did not indicate significant complications or major issues with pain control. The procedure performed is considered a minimally invasive outpatient procedure. The patients perioperative clinical status does not suggest the need for acute inpatient care. Observation status for this patients clinical presentation and postoperative course would have been medically appropriate. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patients condition is severe enough to require inpatient treatment. The current medical evidence does not support inpatient services in this clinical setting. Therefore, inpatient services provided from 1/02/19 through 1/03/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 62-year-old female enrollee has requested reimbursement for substance abuse residential rehabilitation services provided from 2/17/14 through 3/29/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees alcohol dependence and major depressive disorder.  The physician reviewer found that due to multiple factors and unique considerations, determination of the appropriate level of care for patients with addictive disorders complicated by depressive illness and medical comorbidity is a challenging endeavor. Assisting with this process, the American Psychiatric Association (APA) guidelines state that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. This patient had multiple medical problems including thyroid disease and chronic pain. She also had significant depression and had previously made a serious suicide attempt that prompted a one-to-one attendant until 3/3/14. During treatment, the patient received clinically appropriate care for her alcohol dependence and major depressive disorder. The comprehensive services were delivered in accordance with an individual treatment plan. Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness. The placement also provided opportunity for marital harmonization as her spouse attended the family program. Considering the clinical presentation and perusal of the peer-reviewed literature, residential placement with access to specialty services 24-hours a day was a safe, appropriate disposition consistent with good medical practice. Accordingly, the services at issue were medically necessary for treatment of the patients medical condition. In conclusion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 61-year-old male with a history of lower urinary tract symptoms. The patients symptom score is 20. The patient underwent cystoscopy which revealed bladder outlet obstruction. There is also significant post-void residual urine. The patient underwent a prostate biopsy in the past which revealed a low grade low volume low risk prostate cancer. His prostate specific antigen (PSA) is 1.15. He has failed medical therapy including of alfuzosin, Cialis, tamsulosin. The patient elected to proceed with UroLift procedure attempt to relieve his bilateral obstruction and associated symptoms. The provider recommended prostatic urethral lift (PUL) procedure with UroLift. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational. UroLift procedure has been demonstrated to be an effective treatment for well selected patient 50 years of age or older with benign prostatic hyperplasia (BPH). There is good quality evidence to establish the efficiency of PUL in treating symptomatic patients with BPH without adversely affecting the quality of life. Based on the current literature, PUL can be considered as an option for those symptomatic BPH patients with small or medium size prostates 80 ml or less, without median lobe enlargement, who failed on medical therapy or are intolerant, and would like to preserve their sexual function. However, there is a paucity of studies indicating safety of this procedure for a patient with previously diagnosed prostate cancer. Although this patients symptoms are most likely related to bladder outlet obstruction, given the limited data showing long-term improvement in this clinical setting, the UroLift procedure provided on 10/18/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 42-year-old male enrollee has requested authorization and coverage for anterior lumbar interbody fusion to lumbosacral vertebral segment L5 to S1 and two associated inpatient days. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has a history of chronic low back pain and radicular manifestations in the left lower extremity. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability. There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. Per Mummaneni and colleagues, With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft; however, this was not associated with a difference in clinical outcome. The current medical evidence supports the requested services in this clinical setting. Therefore, anterior lumbar interbody fusion to lumbosacral vertebral segment L5 to S1 and two associated inpatient days are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 64-year-old female enrollee has requested authorization and coverage for implantation of a nerve stimulator. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees moderate obstructive sleep apnea (OSA). The physician reviewer found that the Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA. The records provided for review indicate that this patient has not had a thorough evaluation for nasal obstruction. The examination note reports a slightly deviated septum, but no nasal endoscopy is documented to see if posterior deviation is present. Standard therapy options have not been exhausted for the patients possible nasal obstruction or pharyngeal wall collapse. With an AHI of 20.5, conventional proven therapy addressing nasal or pharyngeal collapse is likely to benefit the patient. Thus, the requested implantation of a nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 68-year-old female enrollee has requested authorization and coverage for iStent placement (times two).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports a portion of the services at issue.  The use of iStent implantation in this case is likely more beneficial than any other standard therapy.  However, there is a lack of evidence in the medical literature that simultaneous placement of two iStents is appropriate.  The patient had visually significant cataract causing driving difficulty, and poorly controlled glaucoma on maximal medical therapy.  There is good evidence in the medical literature in controlled clinical trials indicating that treatment with the iStent is safe and effective for the patients disease.  The use of two iStents placed simultaneously is currently being studied.  However, there is no evidence currently that it is more effective than a single implant.  The standard therapy of cataract surgery alone with continued topical medication is not as effective for treating the patients glaucoma.  All told, one iStent placement is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 61-year-old male who was admitted for hospitalization on 8/5/21. The patient 
has requested reimbursement for inpatient hospital level of care from 8/5/21 through 8/7/21. 
The Health Insurer has denied this request and reported that the services at issue were not 
medically necessary for the treatment of this patient. The physician reviewer found that the 
submitted documentation supports the medical necessity of the services at issue. In this case, 
the patient presented with non-ST-elevation myocardial infarction (NSTEMI), a form of heart 
attack, and pulmonary edema in the setting of rapid atrial fibrillation requiring rate control by 
continuous intravenous diltiazem infusion. At the time of presentation on 8/5/21, the patient 
was at risk due to persisting rapid atrial fibrillation, worsening/evolving heart failure, respiratory 
failure,  and  sudden  cardiac  death.  Given  this  adverse  risk  profile,  the  patient  warranted 
admission to inpatient status to facilitate intravenous diuresis or volume removal, close cardiac 
monitoring with telemetry and repeat biomarkers, and continued intravenous infusion for rate 
control to treat the underlying cause of his condition. Moreover, at the time of the inpatient 
order, it was reasonable to anticipate the patient would cross two midnights while receiving 
medically necessary care, often considered the benchmark for inpatient admission, which was 
the case for this hospital stay. In addition, the patient required ICU level care due to (1) his 
pulmonary edema and tenuous respiratory status, and (2) his need for continuous intravenous 
infusion of diltiazem, which cannot be safely delivered on the regular medicine floor in most 
hospital systems. Therefore, inpatient hospital level of care from 8/5/21 through 8/7/21 was 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 56-year-old male with a history of trauma to the left elbow resulting from a fall while bicycling during his vacation in Costa Rica. The patient has requested reimbursement for hospital services provided from 12/26/19 through 12/28/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that this was a complicated situation with an angulated comminuted intra-articular fracture of the proximal ulna and a concomitant fracture of the radial head. The orthopedic surgeon in Liberia did not wish to handle this and transferred the patient to San Jose where, after appropriate workup and preparation, open reduction and internal fixation of the proximal ulna was performed in the early hours of the morning, achieving rigid fixation of the fracture, and stabilizing the elbow joint. This was medically necessary as noted in the literature referenced here. The initial splinting and transportation by ambulance to the appropriate facility was necessary. Surgery was performed in the early hours of the morning at the receiving facility after preparation as noted. The patient stayed in the hospital until the next morning, which was appropriate for pain control and observation because of the location of the facility in Costa Rica. Therefore, hospital services provided from 12/26/19 through 12/28/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the use biologics such as Humira in treating Crohns disease has the potential for serious side effects including major opportunistic infections. This becomes important when a patient loses response to Humira, which entails increasing the dose. The concern between total loss of response or a completely different diagnosis entails different measures varying from surgery, change or increase in dose of biologic to symptomatic adjunct treatment. Hence, a blind management including increase of the dose may beget complications as under dosing compromises disease stability. Therapeutic levels and lack of antibodies may direct the treating provider toward a different drug versus another etiology. In this case, there is concern as the disease is quite advanced and the patient had already failed several regimen and flared on all. Therefore, the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 21-year-old male enrollee has requested reimbursement for inpatient psychiatric hospitalization from 11/20/15 through 12/13/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness.  In this patients case, psychiatric hospitalization was initially indicated and discharge on 11/20/15 would have been premature.  However, the record does not substantiate the need for acute level of care services after 12/11/15.  On 11/18/15, the patient had thoughts of killing his grandmother.  On 11/19/15, the patient was disheveled, constricted and depressed.  On 11/20/15, the patient was depressed, apathetic and helpless.  Thereafter and through 12/11/15, the patient endured mood symptoms, impaired reality testing, paranoia, hallucinations and catatonia, along with an extrapyramidal side effect to one of the antipsychotic medications.  The inpatient team made several medication changes in an effort to optimize the psychotropic regimen, while the diagnosis was not determined until early December 2015.  Based on the illness severity, treatment at the time could not have been reasonably conducted in a less restrictive setting.  By 12/11/15, the patient was taking his medication regularly.  Both his psychotic burden and delusional thought system were markedly less impairing.  His thinking was linear.  He had no suicidal ideation or homicidal ideation.  His insight had improved, and his judgment was good.  Although still symptomatic with a need for long-term specialty services provided by behavioral health care professionals, the acute psychiatric syndrome that prompted the admission had resolved as of 12/11/15.  All told, inpatient psychiatric hospitalization from 11/20/15 through 12/11/15 were medically necessary, but not thereafter.  Therefore, a portion the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 51-year-old male enrollee has requested reimbursement for air transport provided on 8/17/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition status post bicycle crash. The physician reviewer found that air medical transport is a service covered by the health plan when medically necessary. In order for air medical transport to be medically necessary, the documentation must include evidence that the patients condition was such that any form of transportation other than ambulance would have been medically contraindicated; the patients condition was such that the time needed to transport by ground posed a threat to the patients survival; the patient was transported to the nearest hospital with appropriate facilities for treatment; and the patient had a life-threatening medical condition. This patient sustained a brain and spine injury. He was transported from a facility in Hawaii to a facility in California for rehabilitation. However, there are adequate rehabilitation facilities located in Hawaii. Moreover, the transport did not occur to transition the patient to a higher level of care than could have been provided in Hawaii. Rather, the records suggest the patient was transferred to the rehabilitation center in California in order to be closer to home. As such, the air transport provided on 8/17/18 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 46-year-old female with chronic right hip pain. She had undergone labral repairs, debridement, and a periacetabular osteotomy and was still unable to ambulate more than one mile. She complains of pain in the anterior groin and lateral hip described as sharp, radiating, and associated with stiffness. She also has mechanical symptoms in the hip such as catching/locking, giving way, and stiffness. On examination the gait was antalgic. Right hip flexion was 120 degrees, internal rotation was 20 degrees, external rotation was 40 degrees, and extension was 10 degrees. There was pain with range of motion. X-rays revealed medial osteoarthritis with joint space narrowing of the right hip. In 2011, it was discovered that she had severe dysplasia which caused a tear in the right labrum. She underwent a periacetabular osteotomy and repair of the labrum. Due to complications, she underwent four hip surgeries in the subsequent 13 months followed by a fifth surgery in 2015. The labrum tore again a few months later. Treatment options discussed included hip replacement and an AmnioFix injection. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. Degenerative joint and tendon injuries remain difficult to treat in patients with few effective conservative treatment options. Regenerative approaches aim to promote the inherent healing capacity of injured tissues. Micronized dehydrated human amnion/chorion membrane (dHACM) injection is an emerging regenerative option with promising preclinical and clinical results. Gellhorn and Han reported that dHACM was clinically effective in reducing pain and improving function in the majority of adults enrolled in the study. Zelen and colleagues reported there are limited data available regarding most amniotic membrane-based products. However, there is substantial preclinical and clinical evidence supporting the rationale and effectiveness of dHACM allograft as a treatment modality. As such, a trial of micronized dehydrated human amnion/chorion membrane injection (AmnioFix) is a good option for this patient which is likely to be more effective than any other standard treatment for her medical condition.  Based upon the information set forth above, the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services provided from 12/1/15 through 12/29/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the psychiatric RTC services provided from 12/1/15 through 12/29/15 were not medically necessary for treatment of the patients behavioral health conditions. As of 12/1/15, the patient did not cause serious harm to herself or others. She did not require 24-hour supervision for psychiatric treatment. There was no reasonable expectation that the patients symptoms or level of functioning would have significantly improved with residential care. Moreover, the pharmacological changes, therapy progress notes, and treatment planning described do not demonstrate that the patient was exhibiting emotional distress or severe psychiatric symptoms that would require residential treatment. Less intrusive, and less invasive treatment options such as outpatient care could have been reasonably utilized. For the reasons provided, the psychiatric residential treatment center (RTC) services provided from 12/1/15 through 12/29/15 were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.