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

The parent of a seven-year-old male enrollee has requested authorization and coverage for weekly behavioral health treatment with one single child psychologist to ensure consistency and continuation of care for treatment of the enrollees autism and attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that a review of the medical documentation supports medical necessity for weekly therapy sessions with a consistent provider for management of this patients medical condition. The medical records indicate the patient presented with symptoms of mood swings, tantrums, not following directions, aggression, threatening a peer with scissors, meltdowns. An evaluation by a psychologist notes global assessment of functioning (GAF) scores of 51-60. Medication management with a psychostimulant was later initiated and behavioral counseling was recommended. The medical records indicate the patient continued to have problems with aggressive behavior. A psychotherapy note reflects a treatment plan with goals that included decreasing symptoms of depression and anxiety. Given the patients GAF score range of 51-60 documented by the provider and symptoms of ADHD, which are well documented in the medical records, weekly sessions along with consultation with a child psychiatrist is consistent with the community standards of care and the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters. As noted in AACAP guidelines for children with ADHD, co-morbidity should be evaluated and the parameters will indicate the frequency of contact. This patients treatment plan should be reviewed regularly and modified if the patients symptoms do not respond. The need for more intense treatment, including parental involvement, may also be indicated. All told, the requested weekly behavioral health treatment with one single child psychologist to ensure consistency and continuation of care is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair group 4 (HCPCS code K0084 power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds) for treatment of his cervicalgia, lumbar stenosis with radiculopathy, and disc herniation.  The physician reviewer found that in the criteria for a power wheelchair, the Centers for Medicare and Medicaid Services (CMS) criteria include inability to operate a manual wheelchair, bed or chair bound, and the patient must be able to safely operate controls. The patient is not bed or chair bound and has sufficient upper extremity strength to operate a manual wheelchair. In the medical literature, Shnayderman and Katz-Leurer also indicated that walking and aerobic exercise benefits patients with chronic low back pain. The patient has chronic pain and anatomic findings do not reveal spinal cord compression or nerve root compression which would lead to significant lower extremity weakness. Thus, the requested power wheelchair group 4 (HCPCS code K0084 power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is 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 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 whole breast ultrasound for evaluation of her medical condition. Findings: The physician reviewer found that automated whole breast sonography has not attained widespread acceptance which may be related to an element of operator dependence. According to Berg and colleagues Automated whole-breast ultrasonography (US) offers the potential for complete documentation; however, real-time adjustment of scanning pressure, focal zones, and gain are often needed to appropriately analyze lesion features. The issue of operator dependence is a major concern when considering widespread use of whole-breast US. In sum, while automated whole breast ultrasound has been developed as a screening tool, there is a lack of widespread consensus concerning which, if any, additional studies are recommended to evaluate a patient with dense breasts. Therefore, whole breast ultrasound is not medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested services are 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for an MRI of the cervical spine. The enrollee has diagnoses of immune thrombocytopenic purpura (ITP) and immunoglobulin A (IgA) deficiency. The enrollees medical history includes Klippel-Feil syndrome, cervicalgia, spondylosis of the cervical region, fibromyalgia and scoliosis. At an earlier office visit, the enrollee reported neck pain radiating to his shoulders, with dizziness, and with weakness to his hands, which caused him to drop objects. The progress note from the visit indicated the enrollee would require a C 5-6 fusion in the future. At a recent office visit, the enrollee reported several months of frequent episodes of neck pain; especially if he tipped his head backwards. This led to intermittent dizziness. The enrollee has a history of C5 retrolisthesis, which had not been re-imaged for some time. There was no radiculopathy noted in the upper extremities that could correspond with his neck complaint. Magnetic Resonance Imaging (MRI) of the cervical spine for re-imaging of the C5 retrolisthesis has been prescribed. The enrollee has a complex history. Klippel Feil Syndrome is a rare autosomal dominant condition in which there is a congenital fusion of the cervical vertebrae.  He has a history of chronic neck pain and degenerative changes, common in these patients.  Studies found these patients were at an increased risk for developing myelopathy.  The enrollee does not have radicular symptoms, but he does complain of persistent pain and headaches, consistent with upper cervical spine issues.  Given these findings in a high-risk enrollee, an MRI is medically necessary to guide management and prognosis decisions.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee requested Nutropin AQ 20 mg/2 ml for medical treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has normal stature, normal growth velocity, normal bone age, normal growth factors, and no known morphological abnormality of his pituitary gland. Thus, the patient does not have classic GH deficiency.  The fact that his peak GH response to provocative GH testing was less than 10 ng/mL does not, in isolation, point to GH deficiency, as such tests have poor sensitivity and specificity for the diagnosis of GH deficiency in the absence of auxological criteria consistent with this diagnosis.  In sum, the patients adult predicted height is not short enough to warrant treatment with GH on the basis of the U.S. Food and Drug Administrations approved idiopathic short stature indication.
Appeal type: Experimental/Investigational
Decision: Upheld

The mother of a 16-year-old female has requested Botox injections for treatment of headaches.  Findings:  Two physician reviewers found that botox therapy is an accepted treatment for persistent migraine in adult patients who have been given adequate but unsuccessful trials from three or four classes of drugs. This is not the case here. The patient is a minor, and trials of Botox therapy are usually only given to adults. A trial of Depakote, Verapamil, Inderal or Zanaflex may be beneficial. There is inadequate evidence to support the use of Botox in this minor patient who has not exhausted standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested a WalkAide (functional electrical stimulator) for treatment of her multiple sclerosis.  Findings:  Two physician reviewers found that WalkAide functional electrical stimulator is not likely to be more effective for this patient than other available treatment options. This patient has multiple sclerosis and has difficulty with her gait. The WalkAide device has been shown in several clinical trials to be helpful for some patients with upper motor neuron causes of foot drop, including MS and stroke. However, the medical records provided for review do not include any physical therapy assessment of her gait, objective data that supports her improvement with use of the WalkAide, or use of a standard ankle-foot orthosis, which in some patients is very effective in treating the foot drop related disability issues. Given the absence of any records the requested WalkAide is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 16-year-old male enrollee has requested vision therapy for treatment of the enrollees ocular motor dysfunction. Findings:  Two physician reviewers found that the requested therapy is not likely to be more effective for this patient than other available options. Vision therapy for the treatment of the patients diagnoses is not medically indicated. The patient has diagnoses of ocular motor dysfunction, binocular vision dysfunction and accommodative dysfunction. The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with ocular motility disorders, accommodative dysfunction, learning disabilities, and visual field defects (Rawstron et al). Given the lack of evidence for and standardization of office-based treatments, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

The father of a 14-year-old male enrollee requested authorization and coverage of the medication Humatrope. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee requested authorization and coverage of an anterior cervical discectomy with fusion and plating at C4-5, C5-6, and C6-7 for the treatment of bilateral arm numbness.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested authorization and coverage for occupational therapy at a frequency of one time per week.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech and language therapy for treatment of the enrollees stuttering.  Findings:  The physician reviewer found that stuttering is a speech disorder in which sounds, syllables, or words are repeated or prolonged, disrupting the normal flow of speech. These speech disruptions may be accompanied by evidence of anxiety, such as struggling behaviors, rapid eye blinks or tremors of the lips. Many neurologic disorders have been known to cause stuttering. Peripheral nervous disorders affecting the nervous supply of the articulators have been determined to cause stuttering (Andrade and colleagues).  Chang and colleagues examined adult-onset stuttering, which typically occurs following neurological and/or psychological trauma and is considered different from developmental stuttering, which usually starts in early childhood. They found that adult-onset stuttering did not differ significantly from developmental stuttering in any of the speech characteristics measured.   The results of the study by Chang and colleagues suggest that symptoms of idiopathic stuttering can begin during adulthood, and that similar neuroanatomical differences from controls may be associated with both developmental and adult-onset idiopathic stuttering. This fact provides support for the existence of an inherit tendency for stuttering to occur.  Stuttering impacts an individuals ability to communicate. In this patients case, speech and language therapy beyond the date in question was and is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography scan with concurrently acquired computed tomography for attenuation (PET/CT) from skull base to midthigh (CPT 78815). Findings:  The physician reviewer found that PET/CT is a nuclear medicine study that has been demonstrated to be effective in the accurate staging of patients with certain malignancies. However, there is a paucity of data demonstrating the efficacy of PET/CT in the evaluation of this patients pancreatic cancer. As noted by the American College of Radiology (ACR), CT is considered usually appropriate for assessing primary pancreatic malignancy and metastatic disease, while PET/CT may be appropriate to serve as a supplemental imaging modality. Per the American Joint Committee on Cancer (AJCC), PET/CT provides limited diagnostic value for local disease assessment compared to CT or MRI in patients with pancreatic cancer (Amin, et al.). The AJCC noted that PET/CT is primarily recommended for initial staging to assess nodal and distant metastatic disease. Wartski and Sauvanet noted that PET/CT is useful to obtain critical parameters at initial staging to determine treatment in patients with distant metastases. This patient has already undergone evaluation with extensive imaging. All told, the requested PET/CT from skull base to midthigh (CPT 78815) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested PET/CT from skull base to midthigh (CPT 78815) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 diagnostic radiology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 3 is board certified in neuroradiology with subspecialty certification in diagnostic radiology 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: Medical Necessity
Decision: Upheld

The patient is a 41-year-old morbidly obese female with a history of arthritis of the lower spine and left hip. She indicates walking is painful and is seeking a power-operated vehicle (POV) for assistance with ambulation outside the home. The patient is awaiting authorization for weight loss surgery. The Health Plan has authorized a heavy-duty walker for the patient.Review of the submitted medical records does not demonstrate a POV is medically necessary for this patient. The patient has been noted to be ambulatory within her home. She is seeking a POV for community mobility. There is no evidence that she cannot utilize a walker or other mobility assistance equipment. Further she is awaiting approval for gastric bypass surgery, which, if successful, should assist in preventing the need for any mobility assistance. Moreover, the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of an open breast biopsy. The Health Plan denied the request indicating that the requested biopsy is not medically necessary for treatment of the enrollees breast cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested continued use of any narcotic pain medication for the treatment of her chronic pain. Findings:  The physician reviewer found that treatment of pain in such patients or in those with a history of drug abuse or addiction should include consultation with or referral to an expert who can provide skilled assessment and monitoring. Clinicians must always consider the potential for addiction during the treatment of any patient. The experience of pain management programs further encourages caution in the treatment of patients with idiopathic pain, high levels of psychological distress or disability, previous overuse of medical resources or overuse of prescription or non-prescription drugs. The requested medication is not medically indicated or appropriate for this patient.
Appeal type: Urgent Care
Decision: Overturned

A 30-year-old male enrollee has requested emergency services for treatment of his sore throat, chills and flu-like symptoms. Findings:  The physician reviewer found that this patients condition met prudent layperson criteria for emergency care. In this case, the patient presented with a significant sore throat, fever and difficulty breathing. In light of the patients symptoms including his breathing problems and concerns over his airway closing, the patient was experiencing an emergency medical condition with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in jeopardy to the patients health, impairment to bodily function and possible serious dysfunction. Thus, the patients decision to seek treatment in the emergency department was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested a power-operated vehicle (POV for her mobility. Findings:  The physician reviewer found that the durable medical equipment evaluation indicates the patient was observed over several sessions and she was able to propel a manual wheelchair in the home. She was able to navigate on carpeted surfaces and had sufficient mobility for mobility-related activities of daily living. The therapist did not indicate the need for a POV and recommended a light-weight hemi-height wheelchair for the patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested Orthovisc injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found the requested services are not medically necessary for the treatment of this patient.  The current medical evidence does not support Orthovisc injections in this clinical setting.  This patient has been diagnosed with bilateral knee osteoarthritis.  Rutjes and colleagues performed a systematic review and meta-analysis evaluating the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors reviewed 89 trials involving 12,667 adults and concluded that there is a clinically irrelevant benefit and an increased risk of adverse effects.  There is also a documented incidence of aseptic inflammatory reactions due to allergic response and a risk of iatrogenic infection within the joint.  Thus, the requested Orthovisc injections are not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested Orthovisc injections for medical treatment of her knee osteoarthritis.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. In addition, the American Academy of Orthopaedic Surgeons guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.