Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of patent foramen ovale (PFO) and left atrial appendage. Findings:  The physician reviewer found that the patient has a history of melanoma, renal stones, hyperlipidemia and a cryptogenic stroke.  An echocardiogram was performed and reported a patent foramen ovale (PFO) and normal left ventricular function.  A carotid ultrasound revealed no stenosis.  A cardiology report refers to a brain magnetic resonance imaging that reported an embolic stroke in the left thalamus and right cerebellum. The patient has requested authorization and coverage for transcatheter closure of patent foramen ovale (PFO) and left atrial appendage. The Health Plan denied coverage for the PFO closure procedure. Per the Health Plan the requested procedure is investigational for the treatment of this patient.The superior efficacy of the services at issue has not been demonstrated in this clinical setting. Based on the records provided, the patient had a stroke that was presumably due to paradoxical embolization through a patent foramen ovale.  Generally, current literature does not consistently demonstrate improved outcomes with patent foramen ovale closure compared to medical therapy.  For example, one randomized prospective trial performed by Furlan and colleagues did not demonstrate relative benefit of patent foramen ovale closure when compared to medical therapy.  Another trial with results recently available, also showed no significant benefit of closure of a patent foramen ovale compared to medical therapy alone.  Similar results were found in a third recent manufacturer funded randomized trial .  As such, the use of percutaneous closure devices for treatment of a patent foramen ovale in the setting of a documented transient ischemic attack or cryptogenic stroke should be considered investigational. Except in specific circumstances where alternative therapies (aspirin or warfarin) are not tolerated or when alternative therapies are contraindicated or failed, the requested procedure is investigational/experimental. In this patients case, he has no documented contraindication to aspirin or warfarin anticoagulation. Therefore, transcatheter closure of PFO and left atrial appendage is not likely to be more effective when compared to other standard options for treatment of this patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All reviewers are 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 56-year-old male enrollee has requested residential treatment for treatment of his alcohol dependence.  Findings:  The physician reviewer found that the patient has a well-documented history of relapse.  Based on American Association of Community Psychiatrists guidelines, the patient was a candidate for residential level of care. This is based on the presence of serious risk of harm characterized by a pattern of excessive substance use with harmful behaviors and demonstrated inability to abstain from use.  Per these criteria, residential treatment is also indicated when there is a history of poor response to previous treatment.  This patient has demonstrated limited engagement in recovery, which is another indicator for a higher level of care.  Progress notes indicate that the patient was participating in treatment. However, issues related to understanding disease progression and relapse remained.  All told, residential treatment was medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested an artificial disc replacement procedure at spinal level L4-5 for the treatment of her back pain. Findings:  Three physician reviewers found that artificial disc replacement is a unique technique for the surgical treatment of discogenic back pain. However, there is a paucity of controlled studies and clinical trials showing the safety and efficacy of this procedure, particularly as compared to interbody fusion surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) care for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. Note there was limited documentation from an attending psychiatrist at the RTC. The patient was at mild risk of harm (score 2) as the documentation states the patient did not have a history of suicide attempts, persistent suicidal ideation, psychosis, mania, paranoia, or delusions. The patient demonstrated mild functional impairment (score 2) as the provider reported the patient shows only slight difficulty in relational and/or work/school functioning. The patient has a co-morbidities (score 2) including oppositional defiant disorder, unspecified anxiety disorder, and parent-child relational problem. However, the patient does not have any medical problems which require 24-hour monitoring. The patients recovery environment is mildly stressful (score 2) as he was noted to have a mild problem interacting with others. The patients recovery environment is supportive (score 2) and the patient demonstrated significant response to treatment (score 2) in terms of resiliency. The provider noted that the patient responded well to RTC level of care and had improved. Overall, the patient was cooperative, constructive, and participates well in groups (score 2). This gives the patient a composite score of 14, which is consistent with routine outpatient care. Thus, the patient is a candidate for treatment in a less restrictive environment. The patient has made improvements in the RTC treatment and continues to need treatment for his oppositional defiant disorder, unspecified anxiety disorder, and parent-child relational problem, but this can be accomplished at a less restrictive environment. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with expertise 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: Experimental/Investigational
Decision: Overturned

 A 41-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) therapy for TMS therapy for treatment of his major depressive disorder and mood disorder not otherwise specified (NOS). Findings:  Two physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and has developed guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. The attending physician states in her documents that ECT was seriously considered and rejected because of its inherent side effects. Specifically, she does not feel that the patient could tolerate either the anesthesia or the invasive nature of the procedure itself. Several of the above cited articles show that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.  The patient has already had a positive result from TMS, which was a reasonable alternative to ECT in this case.Thus, all told the TMS therapy at issue was and is likely to be more beneficial than other standard therapies available for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old man with some elevation of his LDL and chest pain. He has already had two non-invasive tests, which indicate possible coronary artery disease (CAD). The patients provider has recommended the patient receive a CT angiography. The Health Plan has determined the requested CT angiography is not medically necessary for evaluation of the patients coronary arteries.Based on the current and existing American College of Cardiology (ACC) guidelines, the next step for a definitive diagnosis in cases such as this is a traditional cardiac angiography, if the clinical conditions warrant. The current medical alternatives would be medical observation and treatment of risk factors, medical therapy for presumed CAD or further workup of other causes of chest pain. Despite increasing clinical demands for CT angiography, it is only variably accepted as a useful diagnostic tool. It is the prevailing opinion in the cardiac community that there is insufficient evidence demonstrating CT angiography is as accurate as conventional invasive coronary angiography for screening or detection of CAD indications. According to available evidence-based guidelines, conventional invasive coronary angiography is the standard for assessment of coronary arteries and is superior to CT angiography. As such, the use of CT angiography in this clinical setting is not medically warranted.Based upon the information set forth above, I have determined the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested an MRI scan of bilateral breasts for evaluation of her history of breast pain.  Findings:  Three physician reviewers found that this patient presented with left breast pain which was appropriately evaluated with a diagnostic mammogram and breast ultrasound. The left breast ultrasound showed a probably benign left breast mass which was stable on follow-up ultrasound.  An additional follow-up left breast ultrasound was recommended.  Diagnostic breast MRI is a useful adjunct to mammography and breast ultrasound in select patients.  This includes patients with a new diagnosis of breast cancer, those patients with suspected implant rupture, patients with axillary node positive biopsy for breast cancer with a normal mammogram and when there is concern of recurrent breast cancer involving the area of surgical scarring.  Diagnostic breast MRI is also used when findings are equivocal on physical examination, breast ultrasound and/or mammography.  This patient does not have a new or prior diagnosis of breast cancer.  The patient does not have implants.  There is no documentation that findings on physical examination, breast ultrasound or mammography are equivocal.  As this patient does not meet the published guidelines for diagnostic breast MRI, the breast MRI performed on the date in question was not likely to have been more beneficial than any other available method of evaluating this patient.  Additionally, the requested follow-up MRI scan of bilateral breasts in six months is not likely to be more beneficial for evaluation of the patients medical condition than other available tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested Moviprep and Osmoprep in preparation for her colonoscopy. Findings:  The physician reviewer found that the traditional PEG compounds included on the Health Plans formulary are usually effective and are perhaps the safest preparations for colonoscopy procedures. Moviprep is a PEG solution and is similar to the medications included in the Health Plans formulary. As such, the use of Moviprep was not necessary as appropriate alternatives were available. However, once it was established that the patient could not tolerate a PEG (which does occur in a subset of patients), Osmoprep, a phosphate-containing preparation, was necessary. While phosphate tablets are not the ideal alternative, they are the only other safe and FDA-approved regimen available. The patient and her physician had no other choice than to use a product such as Osmoprep, as the use of another PEG compound likely would have precipitated the same negative reaction. The phosphate tablets (Osmoprep) were better tolerated by the patient in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an anterior hip revision using the same manufacturer of prosthetic as the enrollees current prosthetic. Findings:  The physician reviewer found that the documentation provided supports the medical necessity for the requested services in this clinical setting. This patients clinical diagnosis includes component loosening complicated by a severe maximal rating of pain by the patient. The Orthopaedic Knowledge Update (OKU) noted studies, which compared anterior versus the posterior lateral approach. The studies demonstrated equivalence in terms of component positioning and hospital stay but the comparative studies demonstrated early higher complication rates in patients who have been treated with a direct anterior approach. Modes of failure after total hip arthroplasty include infection, loosening, instability and periprosthetic fracture. Instability has been established as the most common cause of revision hip arthroplasty. In this patients case, the provider noted the instability of the components. This may result from malpositioning or periprosthetic complications or aseptic loosening and osteolysis. The details of motor failure for this patient will be determined at the time of revision arthroplasty as well as whether the same components used in the initial surgery are contraindicated. In consideration of the medical references and the documentation submitted, it is clinically appropriate for this patient to undergo a revision total hip arthroplasty. Accordingly, anterior hip revision, using the same manufacturer as the patients current prosthetic, for treatment of his medical condition is medically necessary.Final Result: The reviewers 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: 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a continuous positive airway pressure (CPAP) machine and supplies. Findings:  The physician reviewer found that the use of CPAP therapy for ongoing treatment of obstructive sleep apnea (OSA) in adults. In this case, the patient has a diagnosis of OSA. The records noted that she was using and benefiting from a CPAP machine and was symptomatic when not using it. Given that OSA is a chronic disease requiring treatment, and that CPAP is the first line of treatment for OSA, the equipment at issue was medically indicated. Therefore, CPAP machine and supplies were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 internal medicine with sub-specialty certification in sleep 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment program services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself, nor was she a danger to others or gravely disabled.  She endorsed passive suicidal ideation, without plan or intent.  This was her baseline state over the many years prior to admission to this facility.  The staff noted her to be low risk for suicide.  Throughout her residential stay, progress was limited in that the predominant themes in her treatment revolved around the patients feelings of being dismissed, neglected, and persecuted by others.  Each month, she missed a number of scheduled therapy sessions. It was unclear if coping mechanisms for her underlying feelings of rage were being worked on or developed. The type and depth of psychotherapy was unclear, as progress reports were monthly and not individual in nature.  Similarly, physician progress notes were sparse.  The medical records do not support residential treatment level of care in this setting. She was struggling with feelings of persecution, dismissal, and alienation from those around her, specifically her family.  The ideal methodology for such patients is placement in a naturalistic setting (home environment) where such conflicts are readily evident and to work on them intensively in a dialectical behavior therapy style treatment, which is by nature outpatient.  All told, residential treatment program services from the date of service forward were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an  enrollee has requested authorization and coverage for 172 hours per month of direct applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and two hours per month of caregiver training. Findings:  The physician reviewer found thatThe Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In addition, a study  evaluated the relationship between ABA treatment intensity and treatment outcomes. The authors found a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made progress in many areas, but continues to demonstrate multiple problematic and dangerous behaviors including elopement, inappropriate touching of strangers, non-compliance and disruptive behaviors. The patient also engages in repetitive gross motor stereotypic behaviors, severity level 3 and obsessive behaviors, severity level 3. The patients ABA provider recommends 40 hours per week of ABA therapy, which is consistent with what is typically recommended for optimal response. For the reasons provided, the request for 172 hours per month of direct ABA therapy, 16 hours per month of supervision and two hours per month of caregiver training are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services at issue 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-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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old female enrollee has requested reimbursement for individual speech therapy services, including augmented alternative communication (AAC) therapy, and feeding therapy services. As noted by a study, patients with 1p36 deletion syndrome greatly benefit from enrollment in a personalized rehabilitation program with attention to motor development, cognition, communication, and social skills. Speech and language delays in 1p36 deletion syndrome are common, with up to 40% of patients reported to have complex speech difficulties. Given that the age of verbal speech onset is significantly delayed, progress can often be slow (a study). It is for this reason that long term speech therapy is recommended. According to this patients speech re-evaluation, the patient has made excellent progress based on standardized test scores. Since starting speech therapy, the patient has improved from non-verbal to vocal, and is using her voice to gain attention and demonstrate desires as well as reject objects and activities. Overall, the patients speech therapy records indicate slow, steady progress, which is typical in this condition. All told, the individual speech therapy services, including AAC therapy, and feeding therapy services provided were medically necessary for treatment of this patients medical condition. All told, the speech therapy services provided were medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.