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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested one hour per week of social skills group training for treatment of the enrollees autism spectrum disorder. The physician reviewer found that the medical literature demonstrates that both ABA and social skills groups are effective for patients with autism spectrum disorder. In this case, the patient receives 15 hours per week of ABA through school and community services. Adding social skills group to this level of intervention is reasonable and appropriate. According to the documentation submitted for review, the patients pragmatic language is the area with the most problems. Practicing pragmatic language one-on-one is less effective than in a group setting. Based on the clinical documentation provided, the patient will benefit from the addition of a social skills group. As such, the request for one hour per week of social skills group training is medically necessary for treatment of the patients autism spectrum disorder.  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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A twenty-two year-old female with a history of caloric restriction and bulimia is requesting reimbursement for residential treatment services.Reviewers Findings:  The reviewing physician found that the patient is in need of appropriate care for the patients serious eating disorder, this calls for 24-hour, supervised medical and nursing care. Yet this is exactly what is missing at the facility where the patient received treatment. The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male enrollee has requested inpatient eating disorder treatment for his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patients case has uniquely complex affective, anxiogenic, addictive, characterological and medical aspects, and to achieve optimal functionality and quality of life parameters, well-coordinated services and likely long-term specialty care will be necessary. However, regarding this particular dispute, treatment at the acute level of care is not medically necessary. The documentation does not substantiate a physically compromising medical crisis secondary to eating disordered behavior. Further, the submitted documentation does not demonstrate the patient is suicidal, homicidal or psychotic, and there is no evidence of grave disability or an acute psychiatric syndrome. Finally, aside from an acute admission in the month indicated, it does not appear that the patient has recently been involved in any type of structured treatment. Thus, there is a lack of evidence of recent trial and failure of less restrictive treatment settings. In conclusion, the requested inpatient eating disorder treatment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees knee pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. According to the documentation submitted for review, the physical examination does not indicate evidence of meniscal or ligament derangement. In addition, the medical records fail to document left knee pain refractory to six weeks of conservative treatment such as nonsteroidal anti-inflammatory drugs (NSAIDS), ice or physical therapy. In the absence of failed conservative treatment, the requested MRI is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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

The parent of a 6-year-old male enrollee has requested 40 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient was diagnosed as autistic about the age of 2 and his assessment at age 3 years and 8 months reported his full-scale IQ as 98. However, his recent report indicates significant cognitive delay. Although has made improvement in multiple maladaptive behaviors over the 2 years that he has received ABA therapy, he has had only modest improvements in vocal stereotype, non-compliance and tantrums. It is well established that ABA or other forms of intensive behavioral interventions are the only successful interventional therapies for many autistic children (Vismara and Rogers). However, there is a lack of scientific literature regarding the requisite number of hours and duration of ABA therapy as a child matures.  While continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. Major improvements are generally recorded after 2 years of intensive ABA therapy (Remington et al).  This patient showed a moderate degree of improvement while receiving 35-40 hours of ABA therapy per week for approximately 2 years. Additionally, his initial intervention was at a very favorable young age. The medical literature supports the reduction of ABA hours to be replaced by school attendance and group social activities as the child ages. Therefore, 25 hours of ABA therapy per week is medically appropriate and necessary. Based on the medical literature cited above and the documentation submitted for review, a portion of the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested a cauterization inner nose procedure (nasal tissue reduction) for the treatment of her sleep apnea. Findings:  Two physician reviewers found that there is quite a bit of support in the literature for cauterization/ablation of the inferior turbinate in treatment of medically refractory nasal congestion secondary to turbinate hyperplasia. However, the main reason that inferior turbinates are operated upon for reduction of their size in the setting of obstructive sleep apnea is to facilitate the use of CPAP when it is not tolerated because of nasal congestion and nasal airway restriction.  In this case, there is no documentation that the intolerance of CPAP is secondary to nasal airway restriction. The records do not describe problems with nasal airway restriction. While multilevel surgery for sleep apnea is generally supported for better outcomes, there is no documented medical indication for this procedure in this particular case.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male has requested Neurolumen PN-1000 device (CPT E1399) and segmental gradient pressure pneumatic appliance (CPT E0673) for treatment of his spinal stenosis.  Findings:  The physician reviewer found that in this case, the patient has been assessed with multiple diagnoses including chronic low back pain, chronic neck pain with cervical radiculopathy, rheumatoid arthritis, osteoarthritis and multilevel spinal stenosis. The provider has proposed treatment with application of low level laser therapy and ultrasound administered through the Neurolumen PN-1000 device. Treatment would be supplemented by the application of a segmented gradient pressure pneumatic appliance. The use of low level laser in chronic, low back pain, neck pain, osteoarthritis and rheumatoid arthritis has been reviewed in a number of published articles where randomized trials of laser versus placebo have been conducted. Three modes of healing energy are proposed to be delivered to the treatment area including low level laser, light-emitting diodes (LED) and transcutaneous electrical nerve stimulation (TENS). Supporters of the therapy contend that the energies administered by the device improve tissue perfusion assisting in the transport of toxins and metabolic waste through from the tissues affected. The efficacy of the requested device relies heavily on patient testimonials. While there have been several reviews of these trials by Cochrane Database Systems Review as well as other authors, these reviews document a lack of standardization of indications, dose levels and application techniques such that no standardized validated outcomes can be reliably extracted from the studies reviewed. Further, there is inconsistency in the documentation of wave length, treatment duration, and the site of application for the above multiple diagnoses involved in this case. The application of low level laser therapy is thought to be effective not by reason of thermal changes such as are present in surgical levels of laser therapy but rather related to unknown photochemical reactions at a cellular level. In the study in Spine authored by Brousseau, et. al., the TENS was noted to have been used for as long as 30 years. The meta-analysis included the review of 5 trials with a total of 170 subjects randomized to placebo. These authors found no significant statistical difference between the TENs group and the placebo group. The authors called for better designed studies and standardization of the TENs devices and application techniques, as well as duration of treatment, frequencies and intensities.  Because of the limited evidence demonstrating the effectiveness of the requested equipment, it is not medically necessary for the patient to receive the proposed combination of low level laser therapy and ultrasound in the management of his chronic pain.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested eating disorder residential treatment center (RTC) for treatment of her eating disorder.  Findings:  The physician reviewer found this patient has profound ego fragmentation which manifests as a chronic and debilitating symptom complex. In reviewing the clinical notes, the patient was symptomatic throughout the disputed timeframe. She had insomnia with negative ruminations and intense urges to purge. Her distorted schemas, anxiousness and depression had not resolved, and she continued to subscribe to a firmly entrenched negative body image. In addition to comprehensive therapy, another psychotropic medication was added to her regimen on a specified date. On that same day, the provider noted continued residential placement was indicated as the patient posed a risk to herself and had not consolidated the treatment gains necessary to maintain weight and eat healthily without purging in an unsupervised setting. Accordingly, the residential treatment was safe appropriate and consistent with the American Psychiatric Association (APA) practice guidelines. Thus, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested extreme lateral interbody fusion surgery for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested surgery in this patients case.  Per the submitted documentation, this patient does not have any significant radiculopathy or significant neurological deficits on clinical examination.  The records submitted for review do not document exhaustion of conservative care.  The peer-reviewed literature does not support the requested surgery absent radicular symptoms and absent documentation of exhaustion of conservative care.  In this patients case, there is lack of documentation of instability or significant stenosis.  The current medical evidence does not support the requested surgery in this clinical setting.  All told, the requested extreme lateral interbody fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested CTA diagnostic testing of the heart for evaluation of his chest discomfort.  Findings:  Three physician reviewers found that in this patients case, there is no objective evidence of coronary ischemia by way of electrocardiographic changes or biomarker elevation in spite of two days of continuous symptoms.  In this circumstance, the likelihood of coronary ischemia is very low such that additional cardiac testing would not be warranted.  Further cardiac testing in this setting is not considered standard accepted practice in the medical community.  Moreover, if additional cardiac testing were thought to be medically necessary, a functional test (stress test) would be preferred and considered more appropriate compared to CTA diagnostic testing of the heart.  CTA diagnostic testing of the heart provides only an anatomic definition of coronary vasculature and does not assess the functional significance of any potential stenosis identified.  Current expert consensus guidelines that are endorsed by several national organizations do not consider this diagnostic procedure appropriate in this setting of low pretest risk, interpretable electrocardiogram and ability to exercise.  All told, CTA diagnostic testing of the heart performed on the date in question was not likely to have been the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cochlear implant procedure on the left side (CPT 95927, 95940, 69930, 69990 and HCPCS L8614).Cochlear implantation for single-sided deafness has been approved by the U.S. Food and Drug Administration (FDA). The FDA criteria requires profound hearing loss in the ear to be implanted and 5% or less word discrimination with monosyllabic words. The patient has a history of Menieres disease with poor hearing on the left side. She had a BAHA, but was unable to use it due to poor benefit, and it was removed. Profound hearing loss is defined as having a pure tone average (PTA) of 90 dB HL or greater at 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz. In this patients case, evaluation on 2/04/21 revealed a PTA of 80 dB HL in the left ear. Thus, this patient does not have the profound hearing loss required to fulfill the FDA criteria currently for the cochlear implantation for single-sided deafness. Thus, the requested cochlear implant procedure on the left side (CPT 95927, 95940, 69930, 69990 and HCPCS L8614) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested Orthovisc injections for the treatment of her torn knee cartilage. Findings:  The physician reviewer found that Orthovisc injections are indicated for the treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and to simple analgesics, such as acetaminophen. The articular cartilage defect(s) described in this case are comparable to osteoarthritis. In view of her age and the findings and failure to respond to the conservative treatments which have been tried, the injection series at issue is reasonable, appropriate and medically necessary for treatment of the enrollees condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 40-year-old male with documented hypogonadism based on low serum testosterone on laboratory testing performed in March 2004. The patient was symptomatic as he experienced fatigue more easily and had early erectile dysfunction. Early topical treatment with patches and gel was not effective. The patient received subsequent treatment with intramuscular testosterone injections every two weeks between April 2004 and October 2004, which was effective. The Health Plan has denied this request indicating the requested injections are not medically necessary for treatment of the patients hypogonadism. The patient has been diagnosed with hypogonadism by his urologist. Laboratory testing was performed. The patients hypogonadism was symptomatic and deemed to require treatment. Review of the records provided indicates topical treatment with patches and gel was tried first. The patches were especially troublesome in that the patient experienced problems with extensive hair requiring shaving and difficulty in maintaining the patches in place. The patients treating urologist notes the topical agents tried were not efficacious. Only after trying the external treatments and finding them ineffective did the patient undergo treatment with the intramuscular injection form of testosterone. This was given every two weeks for a six-month period and proved to be an effective treatment for his medical condition. Testosterone injections are medically appropriate and indicated for the patients diagnosed condition. Based upon the information set forth above, I have determined that the requested injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee requested skin surgery (CPT codes 11404 and 13101) for medical treatment of his medical condition.  Findings:  The physician reviewer found that in this patients case, the records indicate that the dermatofibroma on the chest is asymptomatic.  There is no indication from the record that the provider is concerned about malignancy as a possibility for the chest lesion.  If there is concern for possible malignancy, a biopsy could be performed to determine whether the lesion was benign or malignant.  Given that the dermatofibroma has been asymptomatic and there is no apparent concern for malignancy, removal is not medically indicated.  All told, the requested skin surgery (CPT codes 11404 and 13101) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hyaluronic acid injection. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a hyaluronic acid injection is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Orencia. The enrollee has long-standing, erosive, undertreated, seropositive, class III/IV rheumatoid arthritis, and secondary knee osteoarthritis with large effusions. Her inflammatory markers have been very high, with a Vectra score of 74, showing high disease activity. The enrollee failed leflunomide, and developed mouth sores with methotrexate. She underwent knee aspiration and a steroid injection. She continues to have intermittent pain and swelling in the knees. She does not sleep well due to pain. After a discussion with her rheumatologist, the enrollee preferred to trial treatment with Orencia, instead of triple oral therapy with methotrexate, hydroxychloroquine, and sulfasalazine. Literature notes tumor necrosis factor-inhibitors still represent the first biologic after conventional synthetic disease-modifying anti-rheumatic drug. Literature shows all biologics, including tumor necrosis factor blockers and abatacept, are similarly effective on a long-term basis. A professional society guideline recommends tumor necrosis factor-inhibitors or a non-tumor necrosis factor-inhibitor biologic; with or without methotrexate, and in no order of preference, rather than continuing disease-modifying anti-rheumatic drug monotherapy alone. Orencia is a non-tumor necrosis factor-inhibitor biologic. This enrollee has documented rheumatoid arthritis.  She has already failed methotrexate.  Records show her symptoms continue and she has inflammatory arthropathy involving the knees. In this enrollees circumstances, Orencia is an appropriate therapeutic option.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 rheumatology 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.