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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The discharge summary documents that he made slow but steady progress.  The current medical evidence does not support the services in dispute in this patients case.  The medical records do not show that the patient received any specialized type of treatment during the period in question that could not have been provided in a lower level of care.  Therefore, residential treatment center services were 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance transportation services for treatment of the enrollees Ehlers-Danlos syndrome with positional paralytic apnea. Findings:  The physician reviewer found that the air ambulance transportation services were not medically necessary for treatment of the patients medical condition. There is a lack of documentation demonstrating that the original surgeon was clinically indicated for revision surgery. There are multiple providers closer to the patient that would have been adequate and capable of providing the surgical procedures provided. The proposed surgery could have been provided by any fellowship trained orthopedic spinal surgeon or neurosurgeon with a specialization in spinal surgery.  As such, the services at issue were not medically necessary for treatment of the patients medical condition. 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 neurological 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: Overturned

A 48-year-old female enrollee has requested for total abdominal hysterectomy and anterior repair for treatment her condition. Findings:  The physician reviewer found that anterior vaginal prolapse (cystocele) may be repaired with traditional midline anterior colporrhaphy as is planned in this case, with or without the addition of mesh or graft material, or by paravaginal repair, which can be accomplished vaginally or retropubically by open or laparoscopic access.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested the prescription drug Crestor for the treatment of her elevated cholesterol and LDL levels. Findings:  The physician reviewer found that the alternative medication trial with formulary medication is well within the standard of care for lipid control in a patient who has no history of intolerance to statin therapy. Therefore, the Health Plans denial is reasonable, and it cannot be determined that Crestor is medically necessary for this patient. If the recommended trials of the formulary alternatives are ineffective, then Crestor should be considered for the patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography angiography (CTA) for evaluation of the enrollees end stage liver cirrhosis awaiting liver transplant.  Findings: The physician reviewer found that the requested diagnostic procedure has been established as medically necessary for evaluation of the patients medical condition. CTA of the chest is a radiologic examination of the structures in the chest that allows the clinician to see highly detailed vascular anatomy. The American College of Cardiology (ACC) recommends coronary angiography prior to liver transplantation when the patient has greater than two risk factors due to increased risk of poor outcomes in the transplanted patient with significant coronary artery disease (Raval, et al). The American Association for the Study of Liver Diseases (AASLD) recommends an evaluation of the coronary arteries in patients with diabetes (Murray, et al). In a head to head study, CTA was found to be equally effective as cardiac catheterization in revealing significant coronary artery disease (Moscariello, et al). In this case, an escalating pattern of liver disease manifesting as frequent admissions for liver failure related encephalopathy underscore the need for transplant evaluation. The presence of more than two cardiac risk factors including diabetes, hypertension and kidney disease is an indication of a high risk for coronary artery disease. In this clinical setting, the ACC guidelines support evaluation of coronary anatomy prior to transplantation. In addition, CTA is a reasonable alternative to cardiac catheterization in select patients such as those at higher risk for bleeding complications secondary to invasive catheterization. A patient with low platelet counts and liver failure related coagulopathy is at higher risk for bleeding complications. Therefore, CTA of the chest with and without contrast (CPT 71275) has been established as medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in critical care medicine 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 47-year-old male enrollee has requested for a percutaneous discectomy/decompression for treatment of his low back pain. Findings:  Three physician reviewers found that there are numerous treatments for back pain aimed at removing nuclear material and lowering intradiscal pressure through devices inserted percutaneously into intervertebral discs. Various techniques are utilized in managing discogenic pain, with or without disc herniation. The indications for percutaneous lumbar disc decompression include low back pain and lower extremity pain caused by a symptomatic disc. Cohen and colleagues demonstrated that nucleoplasty is not an effective long-term treatment for lumbar radiculopathy, either alone or with IDET. Endoscopic percutaneous discectomy/nucleoplasty is an experimental procedure without established clinical efficacy. Percutaneous discectomy via endoscopic procedure is not a proven therapy for the treatment of the patients condition, and there is no medical indication for the percutaneous discectomy.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for a dual-energy x-ray absorptiometry (DEXA) bone density test.The patient had a DEXA scan performed one year ago that showed osteoporosis. Records reflect that she completed two years of anabolic agent teriparatide (Forteo) therapy this year. It is known that based on pharmacological mode of action, the effect of teriparatide may be lost after discontinuation of therapy, and, therefore, there are many studies that support sequential or intermittent therapy with an antiresorptive agent. Therefore, it is important for this patient to have a bone mineral density (BMD) study upon completion of therapy and prior to determining subsequent therapy. It would be misleading to require the patient to wait another year before performing a bone density test because of the bone loss that may occur in that period of time. Under these circumstances, a dual-energy x-ray absorptiometry (DEXA) bone density test is 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.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested 52 hours per month of applied behavioral analysis (ABA) therapy and six hours of supervision per month for treatment of his autism.  Findings:  The physician reviewer found that to be medically necessary, a service must be in accordance of generally accepted standards of medical practice, which means it must have support in peer-reviewed literature. Overall, there is a paucity of evidence for providing ABA therapy to adults. The compiled data stresses the importance of early intervention and treatment in the first several years of life. Additionally, it is not clear how the five specific behaviors identified by the functional behavioral assessment would respond to continued ABA. The evaluator noted that the problem of inappropriate touching occurs only when the patient is not closely supervised. The problem of inappropriate exposure occurs on an infrequent basis, reportedly once per year. The problems of food preference, swallowing pills, and fear of dogs are not issues that are best addressed by ABA treatment. In sum, the proposed ABA therapy is not an appropriate modality to address these concerns. All told, the requested 52 hours of ABA treatment each month and six hours of supervision each month is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old female enrollee has requested intensive outpatient therapy for the treatment of her eating disorder and depression. Findings:  The physician reviewer found that this patient has a long history of body image issues as well as a history positive for binging and purging. She has been amenorrheic. Her amenorrhea, obsessions about her body, and a tendency to alternately binge, restrict and purge have persisted. She is also obsessed with exercise, and has a history of laxative abuse as well as self-induced vomiting. She has been alternately underweight and normal weight. She has had symptoms of depression, which commonly arises in patients with eating disorders. She has a history of self injurious behaviors, including cutting. Treatment of this patients eating disorder through intensive outpatient therapy was appropriate and consistent with the standards of clinical practice for management of patients with similar symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested immune cell function assay lab testing for evaluation of her chronic urticarial.  Two physician reviewers found that this patients signs and symptoms are consistent with chronic urticaria. Laboratory evaluation has confirmed this diagnosis via history of autoimmune thyroid disease and evidence of thyroid antibodies. However, the patient had not been treated with standard therapy prior to this visit, thus there was no evidence of failure of primary therapy. The chronic urticaria index is a test which consists of basophil histamine release assay. At this time, the clinical utility of this test is not well established and there are currently no national guidelines recommending routine use of this test. All told, this test is not needed to make a diagnosis of chronic urticaria, guide therapy or follow for clinical disease course. Accordingly, the immune cell function assay lab testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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: One reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing.  Two reviewers are board certified in internal medicine and allergy and immunology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested inpatient psychiatric hospital services for treatment enrollees behavioral health condition. Findings:  The physician reviewer found that upon review of the documentation provided, there was no evidence of acute psychosis subsequent to the patients initial treatment. After the period of initial crisis stabilization, the patient did not present as danger to self or others. All told, the patients symptoms were stable after initial inpatient hospitalization and she no longer presented as an imminent risk to self or others after this period of time. Based on the submitted documentation, the requested inpatient psychiatric hospital services were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 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 has requested reimbursement and prospective authorization and coverage for 35 sessions of proton beam radiation therapy. This patient has unresectable Ewings sarcoma involving the left sacrum. The treating provider has supplied a proton versus photon comparison plan, which demonstrated better target volume coverage with the proton plan and less exposure to surrounding radiosensitive normal tissues, including her reproductive organs and adjacent small bowel. The reduction in dose to her reproductive organs will maximize the chance that she will remain fertile and be able to bear children in the future. The reduction in dose to the bowel will lessen the risk for gastrointestinal toxicity. In addition, the reduction in low dose exposure to her pelvic organs will lessen the risk for radiation induced second malignancy, which can occur decades after delivery of photon-based radiotherapy. Moreover, the American Society for Radiation Oncology (ASTRO) and current peer-reviewed medical literature support the use of proton beam radiation therapy in the management of unresectable Ewings sarcoma. Proton radiation therapy is the most appropriate radiation modality in the patients clinical setting. Therefore, the 35 sessions of proton beam radiation therapy were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 radiation oncology 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: Urgent Care
Decision: Upheld

A 38-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that this patient had been experiencing intermittent abdominal pain for two days. She described it as mild in the Emergency Department. There were no ominous signs of a surgical emergency, such as vomiting or a fever to indicate widespread infection. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. Because her symptoms were not severe or acute in onset with life-threatening symptoms, this patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 18-year-old female with approximately a one-year history of binging and purging, increasing to twice a day in the month prior to referral to residential treatment. She also exercised excessively, running up to seven miles a day, though having discontinued this after four months. Two weeks prior to admission to residential treatment, she told her parents about her eating disorder, was briefly admitted to a behavioral center where she did not eat for about two days, and thereafter resumed eating. Subsequently, she was admitted to the residential treatment center.  During her stay, she was treated with a number of therapies and Prozac, the latter increased to a final dosage of 30mg. She was noted as consistently involved in the treatment program and rather soon compliant with meal expectations.  At issue is whether residential treatment services the patient received from beginning of September 2005 through mid September 2005 were medically necessary.All told, there appears to be nothing to indicate that the patient was not progressing as expected or that she was in such dire condition that inpatient treatment of any sort was indicated as of the beginning of September 2005. All the submitted notes from the end of August 2005 point to the patient as bright, cheerful, and fully involved in the various therapies. As such, she could have been transitioned to some form of outpatient treatment as of that point. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast lift and breast surgery to remove excess skin. This patient has the typical complaints for symptomatic macromastia, but she does not have large breasts. Symptomatic macromastia is a mechanical problem due to the pulling forces exerted by heavy breasts on the musculoskeletal system. Per the records, this patient does not have macromastia. Rather, she has involutional ptosis following weight loss. There is a lack of evidence that correction of breast ptosis without a reduction of breast weight is an effective treatment for musculoskeletal pain. The records do not include office notes that document longstanding musculoskeletal symptoms that have failed to respond to conservative treatments. There is a lack of support for the requested services in this clinical setting. Therefore, the medical necessity of the requested services has not been established.The requested services are not reconstructive in nature. The patients condition does not constitute an abnormal structure of the body. Breast ptosis is part of the normal spectrum of skin structure. Breast ptosis is a normal part of aging and is a normal finding in women who have been pregnant or have lost weight. This condition is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The peer-reviewed literature has not demonstrated that mastopexy is an effective treatment for musculoskeletal pain or is a superior treatment to dermatology management for rashes. Mastopexy will not improve health outcomes and is not clinically indicated. The records do not document a functional deficit which would be improved by this surgery. Mastopexy would not treat her symptom of back pain, even if the underlying problem was macromastia. The records noted that she had low volume, hanging breasts (mostly skin) that would not meet the criteria for breast reduction. Based on the documentation, the requested services are cosmetic in nature. In sum, the requested breast lift and breast surgery to remove excess skin are not medically necessary for the treatment of this patient and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are 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 patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care services. This patient underwent rehabilitation but plateaued with respect to her functionality considering her baseline condition, her bilateral lower limb impairments, and bilateral leg weight bearing restrictions. She remained dependent for transfers, non-ambulatory and requiring maximum assistance for lower body self-care. By the date of the Health Plans denial, there were no ongoing goals, medical, or nursing needs requiring SNF level of care services. Moreover, there is a paucity of evidence to support significant rehabilitation interventions during the period of immobilization and weight bearing restrictions following significant lower limb fractures, outside of obtaining compensatory skill. The records demonstrate that the patient requires custodial care services, not SNF level of care. All told, SNF level of care services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine 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.