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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for home skilled nursing services.Myasthenia gravis is a disorder of neuromuscular transmission that results in fluctuating muscular weakness and fatigue. In adults, the disease is autoimmune in nature, due to antibodies against the acetylcholine receptors in the neuromuscular junction. The congenital myasthenic syndromes, in contrast, are genetic disorders (not autoimmune disorders) that cause the formation of dysfunctional proteins in the neuromuscular junction. Congenital myasthenia is very rare and causes ocular, bulbar and limb muscle weakness of varying severity.In this case, the patient has a congenital myasthenia that has affected his speech, swallowing and respiratory function. He has mild weakness in the proximal upper limbs and in the lower limbs. There is more significant weakness in the distal upper limbs. He is largely independent with his self-care except for activities that require more fine motor function such as tying shoelaces and managing buttons. He is independent with transfers and can walk up to half a mile typically, without difficulty. He does have and use ankle foot orthoses. He requires tube feeds, cough assistance and mechanical ventilation at night. There is a history of autism and some cognitive impairment due to perinatal anoxia with some impaired judgment and safety awareness, but he is in college and able to read and play video games.The records, overall, do not support the medical necessity of skilled nursing services daily. The patient requires assistance for some tasks, which can be provided by a caregiver or other unskilled aide who is trained. He requires supervision due to safety. Medical oversight can be provided by his physician and intermittent home nursing visits. Therefore, home skilled nursing services were not, and are not, medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients 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

The patient is a 36-year-old male who underwent extensive surgery to his left knee, including ACL reconstruction and partial meniscectomy. Postoperatively he utilized a cold therapy unit as prescribed by his orthopedic surgeon. He is now requesting reimbursement for the rental cost of the device. The Health Plan denied his request based upon their determination that the cold therapy unit was not medically necessary following the patients surgery. A cold therapy unit is commonly prescribed by surgeons for postoperative rehabilitation following reconstructive surgery. The cool water is encompassed in a pad that wraps around the knee and is incorporated in the post operative dressing. This device is extremely helpful in relieving postoperative pain and swelling. The pad and unit are easy to use and several studies have shown the cold therapy unit is superior to ice packs alone with respect to postoperative recovery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a nine-year-old male enrollee have requested reimbursement and prospective authorization and coverage for neurofeedback (cognitive rehabilitation therapy) for the treatment of the enrollees history of traumatic brain injury. Findings:  The physician reviewer found that the clinical benefit of neurofeedback for mild traumatic brain injury (TBI) has not been conclusively established, as there is very little evidence in the published medical literature to support the use of this type of therapy for this patients condition. The article cited by the patients parent shows that mild, traumatic brain injuries can cause real problems, but it does not show that neurofeedback is helpful in this setting. Studies show that there is a need for more uniform and standardized assessments. At present, neurofeedback must still be considered an unproven modality for this patients medical issues.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a non-invasive ventilator. In this case, the provider notes that the patient has recovered from COVID-19 pneumonia. While an oximetry study shows frequent desaturation events, raising concerns for sleep disordered breathing, in this clinical setting, initiation of supplemental oxygen at night along with a formal sleep study to ascertain the etiology and optimal treatment for the patients condition is indicated. The records note that the patient is scheduled for a sleep study. Given that there is currently insufficient evidence of the patients sleep disordered breathing pending a formal sleep study, the requested service is not medically indicated. Therefore, a non-invasive ventilator 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 internal medicine with sub-specialty certifications in pulmonary disease and 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services on an emergent or urgent basis.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee was experiencing a psychiatric emergency medical condition. A psychiatric emergency medical condition is defined as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or others  or (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. In this case, the patient did not meet criteria for a psychiatric emergency medical condition as he did not pose an imminent danger to self or others and was able to appropriately utilize food, shelter and clothing. Based on the patients presenting symptoms and through his stay, he was not experiencing a psychiatric emergency medical condition. Further, it has not been established that criteria for urgently needed services were met on the date in dispute. The patients behavioral health conditions were not of sufficient intensity to warrant the services in dispute to prevent serious deterioration of his health resulting from an unforeseen illness, injury or complication of an existing condition. The symptomatology presented initially on admission and throughout the course of stay did not suggest the patients condition was likely to significantly deteriorate absent admission to a residential treatment level of care. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  The physician 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right subacromial ultrasound-guided right bursa injection (CPT 20610 and 76942).Injections under ultrasound guidance have become increasingly popular because of the accuracy and efficacy of the injections. Liao and colleagues performed a retrospective study to identify the treatment response to ultrasound-guided musculoskeletal interventions. Among the 605 injections included in their analysis, there was a positive response in 81% of the interventions, with positive response ranging from 70% to 88% in different groups. As such, ultrasound guidance is effective in musculoskeletal injections and facilitates the accuracy of the injection. In this case, the patient has Complex Regional Pain Syndrome type I and reports severe burning pain in the shoulder at this time. The patient is currently being treated with opioid analgesics, however, this medication is not providing effective pain relief. The provider has determined that the patients pain source is the subacromial bursa. A prior injection into the subacromial bursa with ultrasound guidance gave 50 percent relief. Under these circumstances, the requested right subacromial ultrasound-guided right bursa injection (CPT 20610 and 76942) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested authorization and coverage for post tibial nerve stimulation (PTNS) treatment for treatment of the enrollees neurogenic bladder and urinary frequency.  Findings:  Three physician reviewers found that the patient has a history of pelvic/bladder pain with symptoms of urgency and frequency. The patient was evaluated and diagnosed with interstitial cystitis, chronic pelvic pain syndrome, overactive bladder and neurogenic bladder. The patient has been treated previously with several different types of medications, including pain medications and anticholinergics, without relief of his symptoms. The patients provider recommended a course of posterior tibial nerve stimulation (PTNS).  Although PTNS has been used in clinical practice for over 10 years, only recently have a handful of studies (some non-randomized and some randomized) been published in the peer-reviewed medical literature. The available studies appear to show that PTNS is efficacious; however, the durability of the therapy has not yet been determined. Additionally, the peer-reviewed medical literature has failed to demonstrate that PTNS is superior to other forms of available therapy. Therefore, PTNS remains an unproven efficacy in this setting and requires further study before reports of benefit can be confirmed. As such, there is inadequate evidence that PTNS is likely to be of greater benefit for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 63-year-old female diagnosed with hemorrhoids. Findings:  The physician reviewer found that he patient underwent a screening colonoscopy for malignant neoplasm. The pre-anesthesia assessment documented an American Society of Anesthesiologists (ASA) risk score of one, and a Mallampati class two airway score. The patient was provided with monitored anesthesia care and propofol. At issue in this case is whether monitored anesthesia care that was provided during a colonoscopy on 12/4/18 was medically necessary for treatment of the patients medical condition. The guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) note that the combination of an opioid and benzodiazepine is safe and effective for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Minimal and/or moderate sedation can be delivered safely to patients who are ASA class I, II, or III. The use of anesthesia is associated with a 13% increase in the risk of complications within 30 days and was associated with an increased risk of perforation, hemorrhage, abdominal pain. The medical records noted the patient had a previous colonoscopy without complications. In addition, preoperatively, the patients ASA risk score was rated as one. Therefore, monitored anesthesia care that was provided during a colonoscopy was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 17-year-old female with previously diagnoses of major depression, attention deficit hyperactive disorder (ADHD), reactive attachment disorder, and mild retardation. She was admitted to residential treatment in April 2005 principally for treatment of aggressive behavior.  The Health Plan authorized her stay through early May 2005, but the patient remained at the facility through late May 2005. Review of the treatment notes indicate that much of the patients behavior involved significant lability in the direction of anger alongside self-injurious acts such as cutting and burning herself or hitting walls, and aggressive acts towards others, both verbal and physical. She was treated with a combination of therapies as well as Trileptal, fluoxetine, and Adderall XR. While in treatment she was noted as often disheveled and refusing to actively participate in group. In addition, she was unpredictable and labile in the classroom, and frequently caused disruptions in the therapeutic community and in group therapy by yelling, defying authority, and attaching herself to peers who demonstrated negative and unsafe behaviors. She would often verbally attack her parents, yell, refuse to listen, and would terminate family sessions at her will. At issue is whether the residential treatment services provided from early May 2005 through late May 2005 were medically necessary for treatment of the patients behavioral health problems.Given the extent of the patients lability and aggressive and disruptive behavior, it appears diagnoses of bipolar disorder and certain conduct disorder may have been appropriate. There does not appear to be any documentation supporting the patient as suffering from mild retardation. The patient was admitted to residential treatment initially because of her tremendously aggressive behavior and was treated with a range of modalities including medication treatment aimed at these problems. As documented in the notes detailed above, the patient was not stable by early May 2005. Rather, she appears to have been just as labile, hostile, and aggressive by the end of May 2005 as she was at the beginning of that month. To this extent, the patient was felt to be in need of more treatment, her family still unable to manage her, and she was to be moved to another residential treatment program. What has previously been cited as stable with respect to the patients behavior actually points to the durability of her symptoms. The chronicity of the patients illness demonstrates its severity and supports the need for the services at issue. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female enrollee has requested authorization and coverage for Ef3-Wave Unit (interferential stimulation device) for home therapy for treatment of the enrollees shoulder pain.  Findings:  Two physician reviewers found that the patient has chronic bilateral shoulder pain.  An x-ray of her left shoulder revealed degenerative changes of the left acromioclavicular joint, normal glenohumeral joint, and mild calcific tendinitis.  She has received physical therapy, including manual therapy, exercises, and electrical stimulation.  The patient has requested coverage for Ef3-Wave Unit (interferential stimulation device) for home therapy.  The Health Plan has denied this request and reported that the requested device is investigational for the treatment of this patient.  In this patients case, the current medical evidence does not support the requested interferential stimulation device for home use.  The medical literature does not demonstrate that interferential stimulation is more beneficial for this patients calcific tendonitis than standard treatments.  Although there is limited evidence suggesting some benefit from interferential stimulation, the pain-relieving properties appear to be transient.  There is a lack of evidence showing that the requested device is likely to be more effective in controlling chronic pain than conventional types of treatment.  All told, the requested Ef3-Wave Unit (interferential stimulation device) for home therapy is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested  speech therapy and occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that Stone and Yoder evaluated 34 children with autism at 2 years of age and re-evaluated them 2 years later to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The individuals with significant speech and language intervention improved in their language development (Stone & Yoder). Goldstein reviewed communication intervention for autism in peer-review research articles published over the past 20 years and he indicated that the evidence supported the claim that effective interventions exist to teach communication skills to children with autism. Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Volmar & Wiesner). Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Goldstein).The therapy is indicated when deficits exist in functional skills or occupational performance as well as in areas of self-maintenance and activities of daily living (Goldstein; Dawson & Watling). The goal is to enable the child to participate in daily activities including taking care of oneself, i.e., dressing, bathing, and toileting; and to help the child develop skills such as posture and coordination (Goldstein; Dawson & Watling; and Baranek). The research literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of the autistic childs performance to develop intervention strategies. In sum, the request for speech therapy and occupational therapy is medically reasonable and necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee requested authorization and coverage of the medication Strattera. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cardiac computed tomography (CT) with calcium scoring. Based on the records provided for review, this patient presents with significantly increased coronary risk including mixed hyperlipidemia, abnormal serum protein electrophoresis test results, atypical chest pain, and prediabetes. In this circumstance, the clinical guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary calcium quantification, cardiac CT scanning, advanced lipoprotein analysis, genetic testing, and homocysteine. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis (Stone, et al.; Arnett, et al.). Although the results of some of these specialized tests may be considered independent risk markers for coronary disease, there is a paucity of prospective randomized controlled trials demonstrating improved health outcome benefits with treating routinely obtained abnormal results. Therefore, the cardiac CT with calcium scoring was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the cardiac CT with calcium scoring was 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 services at issue were 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 internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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.