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

The parent of a 1-year, 11-month-old female enrollee has requested for Alimentum ready to feed (RTF) formula for treatment of the enrollees food allergies.   Findings:  The physician reviewer found that symptoms such as abdominal pain, constipation, and regurgitation are relatively common in children. In the medical literature, Heine found that, Gastroesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated. GI food allergy should therefore be considered in the differential diagnosis of infants presenting with persistent regurgitation, constipation or irritable behaviour, particularly if conventional treatment has not been beneficial. For these reasons, the authors suggest that early recognition is essential for the optimal management to prevent nutritional deficiencies and aversive feeding behaviors. Further, Sicherer concluded that, A central aspect of management is periodic reevaluation (oral food challenge) for determination of tolerance, a procedure that often requires the specific expertise of an allergist or gastroenterologist if acute or severe reactions are possible. This patient is a young child with multiple symptoms since early infancy that are highly suggestive of food allergy. As recommended by her provider, appropriate management includes diagnostic studies as determined by a pediatric gastroenterologist and the use of a hypoallergenic formula.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 22 additional hours (total 40 hours) per week of direct applied behavioral analysis (ABA) therapy services (CPT 97153). Based on the guidelines set by the Behavior Analyst Certification Board (BACB), comprehensive ABA programs consisting of 30-40 hours per week treatment intensity are based on the clients response to treatment and current needs. Per the BACB, decreases in hours of therapy per week typically occur when a client has met a majority of the treatment goals and is moving toward discharge. This patients records document diagnoses of autism and ADHD. The patients current behavioral issues support an indication for treatment with ABA therapy services. The patients treatment plan highlights 21 goals. However, the patient has shown significant progress in nearly all of his goals. Based on the number of goals and the patients response to treatment and increase to 40 hours are not medically necessary, as the patient has made significant progress with much fewer hours from previous authorization periods. Additionally, the patient does not meet all of the criteria outlined in the medical necessity definition by Papatola and Lustig. The authors noted that, health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the presenting information, the patient does not meet criterion (c), as the level of treatment is not consistent with scientifically based guidelines regarding ABA services. The patient is noted to be engaged in low levels of maladaptive behaviors. For these reasons, the requested 22 additional hours (total 40 hours) per week of direct ABA therapy services (CPT 97153) 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 a licensed B.C.B.A, board certified in psychology, 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: An enrollee has requested authorization and coverage for custom shoe orthotics.  plantar heel pain is one of the most common musculoskeletal conditions affecting the foot. Contoured foot orthoses have been found to be effective for plantar heel pain. Collected data shows that among conservative treatments for plantar fasciitis such as prefabricated foot orthoses and heel inserts, the greatest reduction of heel peak pressure is achieved by the prefabricated foot orthosis, which provided a fivefold reduction compared to the next most effective insert. The contoured nature of a prefabricated foot orthosis increases the midfoot contact area, resulting in wide distribution of forces in the heel and midfoot. These findings indicate that of the shoe inserts tested, the contoured prefabricated foot orthosis is the most effective at reducing pressure under the heel in older people with heel pain. In this case, given the patients diagnosed plantar fasciitis with associated heel pain, and the demonstrated effectiveness of custom foot orthotics to treat this condition, custom foot orthotics are 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) scan - (CPT 75571) CT heart, without contrast material, with quantitative evaluation of coronary calcium. Numerous clinical studies demonstrate that CAC scoring using ultrafast cardiac CT (also known as electron beam CT) adds predictive value in assessing risk of coronary heart disease (CHD). Budoff and colleagues note that a CAC score of zero was associated with a CHD risk of 1.3% to 5.6%, while a CAC score over 300 was associated with a risk of 13.1% to 25.6%. However, studies have not shown that CAC scoring adds value in the clinical management of asymptomatic patients in whom risk factors are targeted. In an examination of whether CAC scoring in asymptomatic adults had an effect on behavior modification, risk perception, and medication adherence, Mamudu and colleagues concluded that while CAC screening improved medication adherence, the impact of CAC screening on behavioral and lifestyle factors, perception of CHD risk, and psychosocial effects was not statistically significant compared with baseline. Aggressive medication management was the next step in treatment regardless of CAC scoring. Therefore, CT scan - (CPT 75571) CT heart, without contrast material, with quantitative evaluation of coronary calcium was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the CT scan - (CPT 75571) CT heart, without contrast material, with quantitative evaluation of coronary calcium was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for positron emission tomography (PET). According to the American College of Radiology (ACR) recommendations for imaging of the axilla, ultrasound is an appropriate imaging modality for evaluating nodal disease in patients with breast cancer. As noted by the ACR, ultrasound is especially beneficial when the abnormality is palpable, as it allows for directed biopsy, and a pathologic diagnosis. In this clinical setting, ultrasound is considered the first-line imaging modality for evaluation of a palpable abnormality. In addition, there is a lack of support for the use of PET in the evaluation of this patients axilla. Overall, PET has noted limitations in detecting nodal disease in patients with breast cancer. For these reasons, the PET was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology with subspecialty certification in diagnostic radiology 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 an 18-year-old female with a history of a severe eating disorder. There is documented evidence of long-term daily purging. The patient received partial hospitalization services from March 2005 to April 2005. The Health Plan has denied reimbursement for the services the patient received after March 2005. The patient has objective documented evidence of a severe eating disorder. Over a nine-month period there were apparently three days during which the patient did not purge. Upon her admission to partial hospitalization the patient was described as despondent. By March 2005 the patient was progressing with her program but was in need of further therapy at the same level of intensity. The records document that throughout the patients partial hospitalization program she was not appropriate for a less intense level of care until April 2005. The patients condition was such that she required partial hospitalization services from March 2005 to April 2005. There is no evidence that discharge prior to April 2005 was indicated or would have been appropriate.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for subcutaneous implantable cardioverter-defibrillator (S-ICD). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of non-sustained ventricular tachycardia.Findings:  The records indicate that this patient had a normal electrocardiogram tracing during episode of syncope, which occurred while having the implantable loop recorder. Prior work up showed no evidence of structural heart disease. In order to qualify for S-ICD the patient needs to have met criteria for a standard ICD and then have some reason why the subcutaneous model is preferred (such as lack of veins or immunocompromised state). Based on the documentation provided, this patient does not meet the standard ICD criteria. Low ejection fraction has not been diagnosed and no structural heart disease or congenital conduction defect has been shown.  As such, the need for an ICD or an S-ICD has not been demonstrated according to the information available to date. Accordingly, S-ICD placement is not likely to be of greater benefit than the available standard therapy for treating this patients medical condition. Final Result: Two of the three reviewers have 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for prostatic urethral lift procedure performed for treatment of the enrollees benign prostatic hyperplasia (BPH) and nocturia. Findings:  2/3 of the physician reviewers found that the prostatic urethral lift procedure has been approved as an effective treatment of appropriately selected patients who are 50 years of age or older with benign prostatic hyperplasia.  This procedure has shown to be safe and effective in the short term. There is good quality evidence to establish the efficacy of the prostatic urethral lift procedure in treating symptomatic benign prostatic hyperplasia without adversely affecting quality of life. The prostatic urethral lift procedure is an appropriate treatment option for those symptomatic benign prostatic hyperplasia patients who failed medical therapy or are intolerant to it and wish to preserve their sexual function.  Thus, the prostatic urethral lift procedure performed was likely to have been superior over other options for the treatment of this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were 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: The reviewer is board certified in urology 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 40-year-old male enrollee requested Suboxone 8mg-2mg film for the medical treatment of his knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Suboxone is a combination medication containing a partial opioid agonist with a full opioid antagonist.  There is a lack of support for the use of Suboxone for the treatment of this patient.  Suboxone has been approved by the U.S. Food and Drug Administration for opioid dependence.  However, in this patients case, Suboxone has been prescribed for the treatment of chronic pain.  Per the current medical evidence, other alternatives for pain management are more effective in opioid dependent patients.  All told, the requested Suboxone 8mg-2mg film is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has a history of irritable bowel syndrome constipation-predominant for seven to eight years. The patient has requested authorization and coverage for the medication Xifaxan. The Health Plan has denied the request as not medically necessary as the patient has not tried and failed (or is contraindicated to) both ciprofloxacin and amoxicillin/clavulanate.At issue in this case is whether the requested medication Xifaxan is medically necessary to treat the patients medical condition.Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Amoxicillin/clavulanate, the other formulary alternative, is associated with a high risk of adverse gastrointestinal symptoms including antibiotic-associated diarrhea. Results are sustained for several weeks after treatment with Xifaxan. One more recent study has corroborated this finding. A prospective trial of patients with irritable bowel syndrome and a positive breath test found that 86 percent responded to Xifaxan, and symptoms were reduced as well. The dose and duration of 550 mg twice daily for 14 days is consistent with regimens used in studies, which vary widely. The patient has small intestinal bacterial overgrowth confirmed by breath test. The patient has failed treatment with Cipro, Linzess and Trulance. Xifaxan has been proven effective in the treatment of small intestinal bacterial overgrowth. For these reasons, the use of Xifaxan is medically necessary for the treatment of this patients small intestinal bacterial overgrowth.Final Result: The reviewer determined that the requested medication 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 internal medicine with subspecialty certification in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical and occupational therapy for treatment of the enrollee who has a recent history of fractured hip.Findings: The physician reviewer found that there is support in the documentation submitted and in the literature for the requested services. The patient is status post hip fracture as described above. His surgery appears to have been uncomplicated, and he has improved with the treatments provided. However, he has not been progressed to community level mobility and is still unable to perform lower body activities of daily living (ADL) without assistance. He is showing improvement in terms of his ambulation distance and appears capable of further improvement including ambulating on stairs and uneven surfaces. The therapy being requested would reasonably be expected to include a progression to a less restrictive assistive device and use of adaptive equipment for lower body ADLs. There is a reasonable goal of reducing his burden of care enabling him to function independently in the community. For these reasons, the requested physical and occupational therapy are medically necessary for treatment of this 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 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: Overturned

A 55-year-old female enrollee has requested an anterior cruciate ligament (ACL) knee brace for treatment of her medical condition status post ACL reconstruction surgery.  Findings:  The physician reviewer found that it is in the best interest of this patient to be fitted and use the knee orthotic as recommended by her treating provider. In general, it remains controversial as to whether orthotic bracing is needed after ACL reconstruction as part of the postoperative protocol, (Wright and Fetzer). However, the use of an orthotic for prophylaxis in patients who have undergone ACL reconstruction has been addressed through the article authored by Sterett and colleagues. These researchers addressed the issue of whether an orthotic prescribed by a treating physician would likely be effective in protecting patients from recurrent injury. The authors studied a total of 820 skiers who had ACL reconstruction and were divided into one cohort that used a functional knee brace during skiing and a second cohort of skiers who did not use bracing. In conclusion, the non-braced skiers were found to be 2.74 times more likely to suffer subsequent injury than braced skiers. This patients provider noted mild instability coupled with an active lifestyle. Consistent with the findings of Sterett and colleagues, it is in the best interest of this patient to have the custom orthotic as it is likely to be effective in preventing recurrent injury given her active participation in physical activities as an instructor of physical education.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested for psychotherapy for treatment of her condition. Findings:  The physician reviewer found that there is no indication given as to why the patient needs therapy at the continuing rate of four times weekly, as her condition is chronic and not at all acute.  The patient does not appear to need a higher level of care, such as an intensive outpatient program.  In addition, there is no documentation that the therapy given is for symptom reduction. The treatment goals are not measurable and not specific. There is no plan for any type of maintenance therapy.  The patient is also noted not to be in any acute distress that would need a higher level of care.