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

An enrollee has requested reimbursement for exhaled nitric oxide test. The role of fractional concentration of exhaled nitric oxide (FENO) in the diagnosis of asthma remains unclear. The American Thoracic Society (ATS) noted that, FENO values of themselves do not justify a diagnosis or change in treatment. Medical literature states that a systematic review of FENO in the management of asthma in adults. The authors concluded that, FENO guided management showed no statistically significant benefit in terms of severe exacerbations or ICS [inhaled corticosteroid] use, but showed a statistically significant reduction in exacerbations of any severity. This patients records do not include documentation of exacerbations. In addition, the records do not support that FENO testing was utilized in the context of guiding management to prevent exacerbations. Moreover, the Global Initiative for Asthma does not support the use of FENO testing for the diagnosis of asthma. All told, the exhaled nitric oxide test was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found that the exhaled nitric oxide test was not likely to be more beneficial for evaluation of the patients 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 internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy using carboplatin (HIPEC) for treatment of her advanced stage epithelial ovarian cancer with extension to the peritoneal cavity.  Findings:  Three physician reviewers found that the requested services are not likely to be of greater benefit than other treatment options.  The current medical evidence regarding hyperthermic intraperitoneal chemotherapy for the treatment of ovarian cancer does not demonstrate a success rate superior to that of standard intraperitoneal chemotherapy administered in a postoperative adjuvant setting.  The literature has not shown a greater impact of heating the chemotherapy distinct from intraperitoneal chemotherapy administered in a standard fashion.  Thus, the requested hyperthermic intraperitoneal chemotherapy using carboplatin is not likely to be more beneficial than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient multidisciplinary pediatric feeding program. Current medical literature on pediatric feeding disorders supports the use of multidisciplinary programs that incorporate behavioral intervention with nutritional management. Romano and colleagues report that management of non-organic feeding disorders may be on an inpatient or outpatient basis. In an evidence-based systemic review, Gosa and colleagues concluded that joint nutrition and behavior intervention programs, systematic desensitization, and operant conditioning behavioral therapy approaches may be effective in improving the functional feeding and swallowing outcomes in children. In this case, the patient has a limited repertoire of accepted foods, without apparent dysphagia and with ongoing normal growth. While the patients diet suggests deficiency in multiple micronutrients, the records do not show trials of outpatient feeding therapies without improvement. Given the availability of therapy options in outpatient settings, the requested services are not medically indicated. Therefore, an inpatient multidisciplinary pediatric feeding program is not medically necessary for the 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 pediatrics with sub-specialty certification in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve block. Findings: The physician reviewer found that The medical evidence does not demonstrate that the expected benefits of the requested services are more likely to be beneficial than any available standard treatment option. Although, there is some literature to suggest the benefits of peripheral nerve block in pain reduction, most studies call for larger randomized controlled trials and longer follow up. It has also been determined that peripheral nerve blocks work best in conjunction with a formal rehabilitation program. In this patients case, the submitted documentation does not reflect that a formal rehabilitation program has been initiated. Complex regional pain syndrome (CRPS) remains a challenging clinical pain condition. Multidisciplinary approaches have been advocated for managing CRPS. Currently, high quality studies are needed to further evaluate the safety, and efficacy for this treatment modality when managing and treating CRPS. The evidence for its efficacy in this clinical setting is somewhat limited. For these reasons, the requested peripheral nerve block is not likely to be superior over the available standard therapies for treating this patients medical condition.  Final Result: Two of the three reviewers determined the requested services are 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 anesthesiology with sub-specialty certification in pain medicine 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.Nature of Statutory Criteria/Case Summary:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for inpatient hospital stay The submitted documentation supports the medical necessity of the services at issue. This patient had several stroke risk factors, including hypertension and hyperlipidemia. In the acute setting, risk stratification tools are relied on to help guide decision making. A nationally accepted tool included in American Heart Association/American Stroke Association (AHA/ASA) guidelines is the ABCD2 score. This patients ABCD2 score was a 3, placing her at high risk for an ischemic event and warranting further evaluation and inpatient monitoring. Recommendations include admission for patients with an ABCD2 score greater than or equal to three. Additionally, with speech complaints, a cardiac and vascular source must be considered, and the patient was identified to have a large middle cerebral artery aneurysm that required treatment. Therefore, the inpatient hospital stay was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested neuropsychological testing for evaluation of the enrollees attention deficit hyperactivity disorder. Findings:  The physician reviewer found that this patients history does not provide evidence of any factors that would necessitate neuropsychological testing. Specifically, he has no medical or neurological impediment to warrant such evaluation. In addition, the patient has no history of low general cognitive ability or low achievement in language or mathematics relative to his intellectual ability. As such, this patient presented without any risk factors supporting the need for neuropsychological evaluation. Further, there was no documentation of a preliminary psychological assessment to rule out common problems before proceeding to the neuropsychological battery of evaluation. All told, the medical necessity of the testing performed on this patient has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for wearable cardioverter defibrillator rental. Findings:  Two of the three physician reviewers found there is sufficient support for the requested device in this clinical setting. This patient is being treated with guideline directed optimal medical therapy for his cardiomyopathy. There is some likelihood of recovery of left ventricular function in this instance over the initial three-month period with evidence-based medical therapy. Although implantable cardioverter defibrillators have been shown to be beneficial in both ischemic and non-ischemic cardiomyopathy, he does not meet criteria for an implantable cardioverter defibrillator at this point as he requires a minimum of three months of medical therapy for left ventricular dysfunction, and then reassessment of ejection fraction. He is at risk for malignant arrhythmia and sudden death while his ejection fraction is low. He also has evidence of ventricular tachyarrhythmia on his recent Holter monitor. A wearable cardioverter defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period. Therefore, the requested wearable cardioverter defibrillator rental is likely to be superior over other treatment options.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested psychodynamic psychotherapy for treatment of his behavioral health condition. Findings:  The physician reviewer found that Leichsenring and Rabung provide evidence that individuals with chronic, complex mental illnesses seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions are associated with better outcomes. The article by Gabbard explains how this is particularly pertinent in individuals with cluster B personality disorder traits. This patient has chronic, complex mental illness, namely bipolar II disorder and personality disorder with cluster B traits. Psychodynamic psychotherapy is both appropriate and a standard form of treatment for his behavioral health condition. Psychodynamic psychotherapy is most effective when provided more frequently, up to three times per week, as appears to have been the case in this patients treatment. He should therefore continue psychodynamic psychotherapy at the proposed frequency of three times per week.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a now deceased 58-year-old female enrollee has requested for skilled nursing facility services for the enrollees care.  Findings:  The physician reviewer found that the patient had multiple chronic medical problems and a gastric feeding tube. The patient had been cared for at home for several months, and the record does not indicated a significant change in her condition at the time of admission to the skilled nursing facility.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested coverage for Abraxane for treatment of her breast cancer. Findings:  Two physician reviewers found that Abraxane is not likely to be more efficacious than other treatment options.  The National Comprehensive Cancer Network indicates that regimens that are appropriate for adjuvant treatment can be used in the neoadjuvant setting.  The combination of carboplatin, a taxane and Herceptin is well-established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male has requested speech therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that there is substantial medical literature supporting speech therapy and reporting the effectiveness of speech therapy in similar children. Children with speech delay can be readily treated (Law, et al.) and cognitively delayed children, such as this patient, are candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). The standard of care in treating patients with a moderate speech delay, would be for treatment with speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an ultrasound for evaluation of the enrollees left breast pain. Findings:  The physician reviewers found that the American College of Radiology (ACR) has rated the various modalities in terms of appropriateness to screen for breast cancer. An ultrasonography is noted to be usually inappropriate for breast cancer screening in patients with an average risk.  In conclusion, while breast ultrasound is a useful adjunct to mammography, its diagnostic accuracy alone is poor, and it is not recommended as a screening modality. Thus, the request for an ultrasound of the breasts is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested service is 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 reviewers number one, two, and three are board certified in diagnostic radiology and 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 a full electric bed with air mattress, full length side rails, and rail pads.The submitted records do not support that the requested equipment is medically necessary. In this case, the patient has severe cognitive and physical impairments in the aftermath of bilateral strokes. The patient has positioning needs due to immobility with susceptibility for skin and soft tissue breakdown (i.e., pressure injury risk), as well as for feeding due to aspiration risks. With respect to a bed, these positioning needs can be met with a semi-electric hospital bed with an appropriate mattress surface (Gillespie, B., et al.; Chew, H-S., et al.). A total electric hospital bed would also include electric height adjustment. This feature can be necessary for persons who require this feature for independent transfers into and out of the bed. In the current case, however, this powered bed height adjustment feature is not necessary because the patient uses a mechanical lift device for dependent transfers. Height adjustment on a hospital bed is otherwise considered a convenience feature. If height adjustability is desired for the caregiver's comfort while providing care, a bed with manual adjustability (e.g., via crank) can be an option. Under these circumstances, the requested full electric bed with air mattress, full length side rails, and rail pads is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 56-year-old female enrollee has requested the office/outpatient visit, chiropractic manipulation, and ultrasound therapy treatment for treatment of her lumbosacral sprain/strain and lumbar subluxation.  Findings:  The physician reviewer found that the clinical notes lack specific protocol and fail demonstrate the causative factors leading to the patients chief complaints. Further, the records do not report the effectiveness of treatment with pain analogs, improvement in performing activities of daily living, or advancement with exercises. The provider does not document the patients trigger points, which exercises and chiropractic techniques were utilized, and the specifics as to location of electrical stimulation and ultrasound therapies. Overall, the provider is expected to keep and maintain adequate case records clearly showing progression of care, treatment effectiveness, clinical impressions and assessment of a patients condition from visit to visit. In this instance, the records do not support a finding of medical necessity for the physical medicine care provided this patient from the dates in question.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient admission from 10/12/20 to 10/14/20.The 2021 American Diabetes Association guidelines for diabetes care in the hospital indicate that management of hyperglycemia with or without ketoacidosis requires titration of rapid acting insulin and close monitoring of electrolytes. In patients with hyperglycemia with accompanying ketoacidosis, management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis. It is also important to treat any correctable underlying cause of diabetic ketoacidosis (DKA), such as sepsis, myocardial infarction, or stroke. In critically ill patients with DKA or hyperosmolar hyperglycemia, continuous intravenous insulin is the standard of care. In this case, the patients blood sugar level on admission was 557 with documented ketoacidosis. In addition to the DKA, the patient also had diabetic-related hyponatremia, which has significant associated morbidities, including seizures. The patient was appropriately managed with intravenous (IV) fluid administration, IV insulin preparations (low dose sliding scale insulin), and close monitoring of electrolytes. Therefore, the inpatient admission from 10/12/20 to 10/14/20 was medically necessary for treatment of the patients medical condition.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 internal medicine with subspecialty certification in endocrinology, diabetes and metabolism, 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.