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

The enrollee is requesting authorization and coverage for the O-arm stealth machine for 3D imaging, to be used during the L3-4 and L4-5 laminectomy, discectomy, and instrumented fusion procedure. The enrollee has low back pain; extending into his bilateral hip, posterior thighs and calves. The enrollee has diminished sensation to his right posterior thigh and calf. Magnetic resonance imaging of the lumbar spine demonstrates degenerative changes and stenosis at L3-4 and L4-5. He has failed conservative measures of physical therapy and epidural steroid injections. The recommendation from a neurosurgeon was for the enrollee to undergo L3-4 and L4-5 laminectomy/discectomy. This request is medically necessary for both the enrollees safety and for operating room safety, and to decrease the risk of pedicle screw misplacement. The use of the O-arm stealth machine for 3D imaging during lumbar, i.e., L3-4, instrumented fusion significantly reduces radiation exposure and improves the accuracy of screw placement. Studies showed that O-arm navigation, combined with microscope-assisted minimally invasive transforaminal lumbar interbody fusion, results in less blood loss, a shorter hospitalization stay, higher accuracy of pedicle screw placement, and a faster recovery time for the treatment of one-level lumbar degenerative disease.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 neurosurgery 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

An enrollee has requested reimbursement for inpatient hospitalization.The submitted documentation does not support that the services at issue were medically necessary. Inpatient care is necessary when a patient's signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when a patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for a patient to remain in the acute inpatient setting. In this case, the patient was admitted to the hospital in stable condition, and her pain was controlled with oral pain medications. The patient did not require any urgent surgery or procedures, her vital signs were stable, and there was no evidence of shock or significant dehydration or bleeding. While the patient did have contrast leak into her right arm when imaging was performed that caused pain and swelling, this was noted to be resolved and the patients pain was relieved by having the patients arm elevated. The patient was able to tolerate an oral diet and was discharged home the day after admission. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Under these circumstances, the inpatient hospitalization at issue was not medically necessary for 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 internal 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: Overturned

A 20-year-old female has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder, anxiety, and anorexia.   Findings:  Two physician reviewers found that the patient presents with major depressive disorder, recurrent, severe. She presents with depressed mood, problematic concentration and suicidal ideation. She has had two prior suicide attempts. She has impaired functioning socially and occupationally. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Lexapro, Prozac, Zoloft, and Risperdal which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect.  According to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorder. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for this patients depression.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc bilateral knee injections for treatment of the enrollees bilateral knee degenerative joint disease.  Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis were efficacious during a 54-month follow-up period.  Evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient has been diagnosed with osteoarthritis of both knees.  The patient has undergone prior arthroscopic surgeries bilaterally. She has undergone two prior series of Orthovisc injections which resulted in long-term pain reduction.  The patient has worsening bilateral knee pain and functional impairment that has failed to respond adequately to other conservative treatment.  All told, the requested Orthovisc bilateral knee injections are medically indicated for the treatment of this patient.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: Overturned

The treating provider of a 33-year-old female enrollee requested authorization and coverage for an allogenic stem cell transplant for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees acute myelogenous leukemia.All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy, the health plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of four-year-old female has requested occupational therapy and speech therapy for treatment of her autism. Findings:  The physician reviewer found that children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, social skills training, and behavioral therapy. Deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children. Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. (Case-Smith and Arbesman) With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well suited to affect positive change in children with ASD. (Smith-Roley, et al.) Occupational therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees developmental disorder with speech delay and autism.  Findings:  The physician reviewer found that the assessments made by psychologists, the patients parents and the special education teachers observations confirm a diagnosis of autism. As the patient is autistic, ABA therapy is medically necessary. The medical community considers ABA therapy the standard of care given its well-documented record of substantially improving motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in autism spectrum disorders (ASDs) has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In sum, this patient has been diagnosed as autistic and ABA therapy is clinically indicated in this patients case. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, as of 6/19/17, the patients risk of harm score is four (4), serious risk of harm. The patient recently overdosed on her prescription medications due to marital conflicts at home. The patient has a history of prior suicide attempts. Per documentation, the patient has dependent personality disorder, and if husband continues to talk about divorce, it is likely that the patient will again attempt suicide. The patients functional status score is three (3), moderate impairment. The patient has a recent conflicted relationship with her husband. She has been unable to fulfill her responsibilities at home and has been depressed and isolating. There have been some improvements while she has been hospitalized in regards to her mood. However, when the patient was told that she would be discharged from the RTC, she was described as hysterical. The patients medical, addictive, psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of major depressive disorder and a history of breast cancer. She has a history of many prior inpatient hospitalizations and prior suicide attempts. The patients recovery environment score is four (4), highly stressful environment. The husband threatened divorce which led the patient to overdose on medications. The patients level of support score is three (3), limited support in the environment. The patients husband is supportive, but their marriage is currently under distress. The amount of support he can provide is limited, though he does seem willing to participate in martial therapy treatment. The patients treatment history score is three (3), moderate response to treatment and recovery. The patient did have some modest gains while in the inpatient unit as far as improving her mood. However, the patients partial recovery has only been maintained for moderate periods of time with strong social support and in structured settings. The patients engagement and recovery status score is three (3), limited engagement in recovery. The patient at times will cooperate with treatment if she feels that her needs have been met. Based on these criteria, the patient has a total score of 23 and met criteria for a RTC level of care. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested a bilateral breast magnetic resonance imaging (MRI) for evaluation of her left breast skin thickening.  Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be superior over other available modalities for evaluating this patient.  The medical records note an area of persistent skin thickening in the upper outer quadrant of the left breast which is separate from a known, unchanged, benign appearing mass.  The mammogram is of limited value due to extremely dense breast tissue, and the ultrasound was negative.  In this patients case, biopsy is not the procedure of choice since the provider cannot be certain that an infiltrating tumor, if present, will be located in the biopsy sample.  The requested MRI is very sensitive for the detection of breast cancer.  In this clinical setting, the requested MRI is likely to be more efficacious than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an acute inpatient psychiatric stay for treatment of his behavioral health condition. Findings:  The physician reviewer found that although treatment gains are optimized in community-based settings, more restrictive levels of care are often necessary to address exacerbations of chronic mental illness. In this case, the patient is diagnosed with a formal thought disorder, which as a class represents the most severe psychiatric disorders. After reviewing the record, discharge would have been inconsistent with good medical practice. Treatment at the time could not have reasonably been conducted at a less restrictive setting while less intensive services would have resulted in inadequate care. The patient endorsed both auditory and visual hallucinations. His thought processing was tangential and illogical. He was deemed gravely disabled. The inpatient team began a cross-tapering of the antipsychotic medication and recommended further work-up including neuroimaging and electroencephalography. Thus, the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting. Thereafter, the patients illness burden remained largely refractory to treatment. The inpatient team changed his antipsychotic medication. The patient remained disorganized and internally preoccupied. The patient does have a supportive family, which will be instrumental in his recovery. However, he will more than likely decompensate and require prompt re-admission in the event of a premature discharge. Currently the patient remains consumed by an acute psychiatric syndrome. Thus, inpatient psychiatric care remains reasonably expected to improve his condition and prevent a more serious episode of illness. The setting is safe, appropriate and consistent with good medical practice. Thus, the services in dispute have been and remain medically necessary for treatment of the patients behavioral health condition.  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 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: The patient has requested authorization and coverage for use of a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. In this case, while the records indicate that the patient has various chronic pains, including chronic back pain, and severe congestive heart failure, the records did not document neurological weakness or impairment. Functionally, the patient was observed to have poor endurance and an unstable gait when walking without an assistive device. In the setting of this patients multiple health conditions, including low back pain, a degenerative spine, deconditioning, and obesity, current medical literature supports encouraging increased levels of light, physical activity and exercise, such as walking. Baena-Beato and colleagues report that aquatic therapy programs may decrease levels of back pain and disability. Forhan and Gill note that obesity is a health condition that is associated with mobility disability. Hagen and colleagues conclude that there is empirical evidence that exercise therapy has beneficial clinical effects on most musculoskeletal conditions. Given that the submitted records, overall, do not indicate that the patients mobility difficulties with activities of daily living or community access could not be addressed with a gait implement such as a walker, or by a manual wheelchair, the requested equipment is not medically indicated. The records, in addition, do not indicate that the patients home is accessible to a power mobility device given that it has narrow doorways and is on the second floor without indication of elevator access. Therefore, use of a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community, is not medically necessary for the treatment of this patient.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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc injections for treatment of the enrollees chronic knee pain. Findings: The physician reviewer found that Evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient was diagnosed with advanced osteoarthritis of both knees. She underwent prior right knee arthroscopic surgery. She has undergone multiple viscosupplementation injections at least three times with pain reduction and improvement in function. She has worsening bilateral knee pain and functional impairment that has failed to respond adequately to other conservative treatments, including medications, activity modification, physical therapy, and bracing. In sum, the requested Synvisc injections are medically necessary for treatment of this patient.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.