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

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for air ambulance transport services provided on 3/30/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.  The physician reviewer found that according to the documentation submitted for review, a then relatively healthy 61-year-old female sustained an isolated closed distal femur fracture after falling down an embankment. She was brought to ED where the record reports orthopedic surgical care was unavailable. According to the American Academy of Orthopedic Surgeons (AAOS) practice guidelines femur fracture in the elderly should be treated with urgency (within 48 hours). The decision to transfer care to another center was therefore appropriate, as there was no indication when orthopedic care would be available. However, the decision to transfer to a center in Santa Rosa, as opposed to the closer facility in Redding is not entirely clear, based on the submitted records. There is no statement as to whether or not orthopedic surgical was available in Redding. Regardless, there is a lack of documentation that the patient was hemodynamically unstable. In addition, the patient did not meet the criteria guidelines from the American College of Emergency Physicians to warrant air medical dispatch. Traction splinting in the field and ground transport is sufficient for stable patients with isolated femur fractures. Spiral fracture patterns, as reported in the submitted records, can occur with relatively low energy mechanisms, particularly in the elderly, and associated complications such as compartment syndrome in these types of fractures is extremely low. In addition, based on the records, the air transport did not significantly shorten the time to definitive care. In this case, the use of air ambulance transport services provided on 3/30/14 was not medically necessary. Therefore, 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: Overturned

Summary Reviewer 1

A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. Drug induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate the continuous positive airway pressure device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device given the intolerance to continuous positive airway pressure, anterior posterior collapse, and body mass index within FDA criteria. Therefore, 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 39-year-old female enrollee has requested reimbursement for residential substance use disorders treatment provided from 11/15/19 through 11/23/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that per American Society of Addiction Medicine (ASAM) criteria, the patient meets Level 3.5 criteria, or clinically managed high-intensity residential services. With regards to dimension 1, intoxication/withdrawal potential, the patient has a history of complicated withdrawal. In terms of dimension 2, biomedical conditions and complications, the records document new onset seizures during detoxification and unsteady gait requiring walker with assistance. With regards to dimension 3, emotional, behavioral or cognitive conditions and complications, the records note comorbid depressive disorder and posttraumatic stress disorder. In terms of dimension 4, readiness to change, the patient is willing to change, but was not yet able or ready. Per the records, she qualified her motivation to engage and learn new things with, It depends on what it is. With regards to dimension 5, relapse, continued use, or continued problem potential, the patients longest sobriety prior to this was while pregnant a few years prior. In terms of dimension 6, recovery/living environment, the records document a supportive husband and mother. However, the patient reported that there was a very large wine collection at home. Prior to admission, she was able to hide her drinking from others. Given the severity of the patients illness, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Therefore, residential substance use disorders treatment provided from 11/15/19 through 11/23/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 65-year-old female enrollee has requested reimbursement for Cx Bladder testing performed on 7/02/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the records document asymptomatic microscopic hematuria. Cxbladder testing is not a screening test for urothelial cancer in patients with hematuria. Cystoscopy and possible biopsy and upper tract imaging may still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as Cxbladder testing may provide false-negative results in patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology, but there is lack of validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. However, further prospective validations are needed to confirm these findings. Therefore, Cxbladder testing performed on 7/02/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 19-year-old male enrollee has requested authorization and coverage for lumbar disc 
arthroplasty and two inpatient days. The Health Insurer has denied this request and reported 
that the requested services are investigational for the treatment of the enrollees medical 
condition. The physician reviewer found that lumbar disc arthroplasty is indicated for 
discogenic low back pain. In this case, the records noted both back and leg pain. MRI 
demonstrated a large herniated L4-5 disc. Anterior approaches to the lumbar spine are not 
appropriate for resection of a herniated lumbar disc. There is a lack of support for the 
requested services in this clinical setting. Therefore, the requested lumbar disc arthroplasty and 
two inpatient days are not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 61-year-old male enrollee has requested reimbursement for MRI performed on 5/20/19. The Health Insurer indicated that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient was evaluated with bilateral shoulder MRI. The MRI was grossly positive bilaterally and showed significant internal derangement on both sides. He had severe pain with both internal and external rotation maneuvers on physical examination. While not referred to by name, this phenomenon constitutes a positive Hawkins test and reflects high probability of rotator cuff disease. A positive Hawkins test is a reliable indicator for rotator cuff pathology. In this circumstance, a conservative course of therapy is not required prior to MRI. While a plain film series is usually performed prior to MRI, those films would not have negated the necessity of MRI, since the tendons and joint lining of the shoulders are not visible without MRI. Therefore, MRI performed on 5/20/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for stereotactic body radiotherapy. 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 fails to demonstrate the medical necessity of the requested services. This patient has progression of her breast cancer following standard chemotherapy. Standard treatment in this setting is with second-line chemotherapy and palliative radiation to her spine for pain. There are cases when patients with certain histologies (colorectal, lung and breast) with limited metastatic disease who are eligible for stereotactic body radiotherapy. However, this patient does not have oligometastatic disease, as she had widespread metastases at the time of presentation. There is a lack of convincing medical evidence that suggests that patients with widespread breast cancer benefit from stereotactic body radiotherapy for spine metastases. Therefore, stereotactic body radiotherapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a five-year-old male enrollee has requested reimbursement for air ambulance services from Los Robles Hospital to Ronald Reagan UCLA Medical Center on 5/31/18. 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 this patient arrived tachypneic, tachycardic, and with a low oxygen saturation. He received two doses of racemic epinephrine for croup. The records document rebound symptoms despite steroid treatment. He remained tachypneic and tachycardic, placing him at risk for respiratory failure.  Although this patient had been appropriately treated and his symptoms had improved, the on-call provider recommended that the patient be transferred in order to receive a higher level of care than could be provided at Los Robles Regional Medical Center, the pediatric intensive care unit at Ronald Reagan UCLA Medical Center. Ground transport time at that time was estimated to be 1 hour and 14 minutes. Therefore, air ambulance transport was medically appropriate in this case. Thus, air ambulance services from Los Robles Hospital to Ronald Reagan UCLA Medical Center on 5/31/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Prolia. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis, and this can lead to acute and chronic pain as well as increased mortality. A newer medication, denosumab (Prolia), is a fully human monoclonal antibody that has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. The 2019 Endocrine Society guidelines on pharmacologic management of osteoporosis note that Prolia is indicated as an alternative initial treatment for postmenopausal women with osteoporosis at high risk for fracture. In this case, the patient has osteoporosis confirmed by DEXA scan and breast cancer, which increases her risk of osteoporotic fracture. Based upon clinical findings and the 2019 recommendations of the Endocrine Society, Prolia is a medically necessary initial therapy for osteoporosis. Therefore, Prolia is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 26-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 9/7/18 through 9/18/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines state that RTC is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. During the period under review, this patient required safe and stable living environment in order to develop recovery skills. Applying the American Society of Addiction Medicine (ASAM) guidelines, this patient met the criteria for Level III treatment, consistent with RTC level of care. The standard practice for RTC level of care services is a 30-day program, which was appropriate for this patient given her difficulty with family relationships and significant trauma history placing her at elevated risk for relapse. RTC level of care services was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Thus, the RTC services provided from 9/7/18 through 9/18/18 were medically necessary for treatment of this patients behavioral health issues. Based on this discussion, 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: Overturned

Summary Reviewer 1

The parent of a 12-year-old male enrollee has requested authorization and coverage for functional electrical stimulation RT300 therapy system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees incomplete paraplegia. The physician reviewer found there is sufficient support for the requested device in this clinical setting.  This patient has a complicated medical condition that affects his activities of daily living as well as physical and psychosocial development as he matures into adulthood.  Since this patients condition is thought to not to be autoimmune mediated, standard immunotherapy and anti-inflammatory therapies would not be beneficial.  In this patients case, treatment is relegated to regaining as much function as possible.  Standard therapy in this case would be both active and passive physical therapy which the patient has already been receiving.  The medical evidence supports functional electrical stimulation in this patients case.  All told, the requested functional electrical stimulation RT300 therapy system is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested device 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 43-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 7/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient was diagnosed with endometrial cancer. The patient had a hysterectomy and bilateral salpingo-oophorectomy, and the final pathology showed an endometrioid adenocarcinoma. A portion of the tumor tissue was submitted for the FoundationOne CDx test. The test performed microsatellite assessment, tumor mutational burden, as well as an analysis of mutations in over 400 known tumor suppressor and oncogenes. Endometrial cancers have been analyzed in depth, and the current pathology work-up recommends detailed molecular analysis. These recommendations are present in the National Comprehensive Cancer Network guidelines. Based on the current standard of care, the testing as ordered was medically appropriate. Thus, FoundationOne CDx testing performed on 7/16/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 52-year-old male enrollee has requested reimbursement for acute hospital admission at telemetry level of care provided from 2/13/18 through 2/14/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had known coronary disease and presented with atypical (at rest) chest pain without any objective evidence of coronary ischemia or hemodynamic instability.  In this circumstance, it would have been reasonable to anticipate a hospital length of stay less than two midnights, and it would have been safe to manage the patient at an observational level of care as opposed to a hospital admission. After the initial evaluation, it was not likely that the patient had an acute coronary syndrome based on the above findings. Thus, acute hospital admission at telemetry level of care provided from 2/13/18 through 2/14/18 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 
 
A 45-year-old female enrollee has requested reimbursement for repair of blepharoptosis provided on 2/4/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees left eyelid ptosis.   The physician reviewer found that the report by the American Academy of Ophthalmology (AAO) has outlined the indicators that ptosis repair can lead to functional improvement. The AAO state that, repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. The AAO guidelines indicate that preoperative indicators of improvement include margin reflex distance 1 (MRD1) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. This patient meets many of these criteria as her superior visual field is reduced from about 50 degrees to about 37 degrees, which is a reduction about 26%. Moreover, the patients MRD1 is 2 mm. In addition to these criteria, the patients dry eyes will likely improve with a conservative blepharoptosis repair (Vold, et al). All told, the repair of blepharoptosis provided on 2/4/16 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 57-year-old male enrollee has requested reimbursement for residential treatment services provided from 11/12/14 through 12/3/14. 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 based on the above information, the patient did not meet medical necessity criteria for residential treatment services from 11/12/14 through 12/3/14. There is no evidence that less intensive treatment was not sufficient or appropriate to effectively treat the patient, since he had participated in an adequate trial.  The patients level of symptomatology did not justify continued residential treatment during the period at issue. No suicidal ideations or homicidal ideations were documented. The patient did not show evidence of serious psychomotor excitation or aggression. Severe affective dysregulation was not reported. The patient did not appear to have any serious psychosocial functional or interpersonal skills deficits. Furthermore, the patient has not attempted less restrictive, less intrusive services prior to the admission at issue. At the time of admission it was noted that the patients affect was labile but there was no evidence of psychosis, and no evidence of suicidal or homicidal ideation. Multiple progress notes including on 11/5/14 and 11/10/14 noted good mood, no suicidal ideations and no evidence that suggested a need for 24-hour care. All told, there was no reasonable expectation that residential care would have significantly improved the patients symptoms over a less restrictive level of care such as outpatient individual counseling and outpatient medications management. For the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 15 additional hour per week of applied behavior analysis (total of 40 hours per week) from 1/16/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically for treatment of the enrollees medical condition. The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. However, the medical research is inconclusive on the amount of hours of ABA indicated for patients in this clinical setting. In addition, there is a lack of head-to-head studies comparing 40 hours per week of ABA services to 25 hours per week. Reichow and colleagues found that early intensive behavioral intervention (EIBI) was effective for treating children with autism and the average amount of ABA therapy was 25 hours per week. In this case, the data provided for review demonstrates that the patient has been making progress with 40 hours per week of ABA therapy. However, there is a lack of documentation showing regression, increase in behaviors or worsening problems due to a decrease in ABA services. In the absence of documentation demonstrating the patient has made slower progress or had a regression with a decrease in ABA services, the services at issue have not been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.