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

A 64-year-old female enrollee requested continued skilled nursing facility (SNF) services for medical treatment of her left total knee prosthesis infection.  Findings:  The physician reviewer found that the patient receives antibiotic treatment via a PICC line, which typically requires skilled nursing services to assess for and prevent infection and proper administration of medications.  In addition, the patient has a history of significant infection to the knee, which requires monitoring from skilled medical personnel to assess for possible reinfection of the joint.  Furthermore, the patient lives alone and has significant functional deficits, as such it would not be appropriate to send the patient home with such significant deficits to include the inability to use the left lower extremity.  Moreover, the functional deficits that are currently present would require the treatment of skilled therapy services.  Therefore, the continuation of skilled nursing facility services is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). Adenocarcinoma of the lung should be evaluated for specific molecular abnormalities which have known clinical implications. Such testing is usually performed from the tissue biopsy, but can also be done from liquid assay with Guardant360. Tissue biopsy is preferable and more accurate. However, in this case, the tissue biopsy was reportedly not sufficient for such analysis. Therefore, it was elected to use the Guardant360 assay rather than attempt another tissue biopsy. Given these findings, the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the blood test (Guardant360 biopsy-free tumor sequencing test) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncologyand is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of a DEXA scan. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested DEXA scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ruxolitinib. Findings:  The physician reviewer found that Ruxolitinib is U.S. Food and Drug Administration (FDA) approved for the treatment of polycythemia vera with an inadequate response to or intolerance to hydroxyurea. Ruxolitinib is currently considered the standard of care in well selected patients as shown in several clinical trials. Vannucchi and colleagues concluded that for patients who had an inadequate response to or had unacceptable side effects from hydroxyurea, ruxolitinib was superior to standard therapy in controlling the hematocrit, reducing the spleen volume, and improving symptoms associated with polycythemia vera. This patient is intolerant of Hydrea and carries a mutation making him at higher risk for myelofibrosis. All told, the requested ruxolitinib is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication 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 internal medicine with subspecialty certifications in medical oncology and hematology 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

Nature of Statutory Criteria/Case Summary:    An enrollee has requested intensity modulated radiation therapy with x-ray guidance for treatment of her medical condition.  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  This patient has locally advanced gallbladder cancer which is a clinically rare condition.  Intensity modulated radiation therapy with x-ray guidance has been utilized to treat several malignancies, including upper abdominal malignancies.  There are few published data pertaining to intensity modulated radiation therapy for biliary-pancreatic area, and there is a lack of randomized or large cohort trials supporting the requested services in this case.  Thus, the requested intensity modulated radiation therapy with x-ray guidance is not likely to be more effective than other modalities.  Final Result: Two 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:  All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested outpatient psychotherapy services at a frequency of five times per week for treatment of her depression and anxiety attacks.  Findings:  The physician reviewer found that the treatment that this patient is currently receiving, which is psychoanalysis five times weekly, does not appear to be either an effective or an appropriate treatment plan for this patient. The providers notes indicate that after months of treatment, the patient has severe abandonment issues, not with her husband, but with the provider. It is well known that in psychoanalysis, the patient develops a transference reaction toward their therapist. However, the notes seem to indicate that this transference is not being appropriately handled and that it is causing the patients symptoms to worsen. Further, a review of the American Psychiatric Association (APA) guidelines for treatment of anxiety disorder, the diagnosis given by the psychiatrist, suggest that cognitive behavioral therapy (CBT) is indicated and should be combined with medications if not effective. Given this patients severe traumatic history, she may meet the criteria for post-traumatic stress disorder (PTSD) as well. Brief psychodynamic therapy is listed as occasionally being helpful for patients with PTSD in specialized situations. All told, the outpatient psychotherapy services provided at a frequency of five times per week, during the said timeframe is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year, nine-month-old male enrollee has requestedfor speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Law and colleagues reported that children with speech delay can be readily treated. These findings are consistent with the publication from Goorhuis-Brouwer and Knijff who found that verbal and non-verbal development can improve in young children with developmental language delay.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patient has a significant expressive speech delay with a mild mixed receptive component. The receptive component may be due to the home language being non-English. The patient is intellectually normal but cannot generate adequate speech for his age. With one hour of weekly speech therapy, his expressive language increased in a 5 month period from 12 months to 15-16 months of age equivalent speech. The standard of care within the medical community for a young patient of normal intelligence with these language delays is speech therapy. There is strong evidence in the medical literature that confirms the validity and effectiveness of speech therapy. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in a summary of multiple medical journal articles. Further, Goorhuis-Brouwer and Kniff evaluated speech-delayed cognitively normal and abnormal children, and emphasized that intellectually normal children, such as this patient, are ideal candidates for successful speech therapy. Consistent with these data, the requested speech therapy is medically necessary for this patient. He should receive individual speech therapy for a minimum of one hour weekly for six months with reassessment at the six month interval. The speech therapist should be fluent in both English and the non-English language spoken at the enrollee's home to assist in parental education.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested lumbar spinal fusion for medical treatment of his low back pain radiating down the right leg. Findings:  The physician reviewer found that this patient fails to meet criteria for lumbar fusion as he does not have a lumbar radiculopathy or spinal stenosis with spondylolisthesis and neurogenic claudication. Moreover, he has not been treated with cognitive behavioral therapy and there is no documentation of epidural steroid injections and physical therapy within the last six months. He has no evidence of instability, infection, fracture, or tumor. He has no evidence of recurrent disc herniation, pseudarthrosis, or adjacent segment degeneration. According to the radiologist, there is a small protruding disc at L4-5 without evidence of nerve compression. This indicates that there is no pinched nerve. Even if there were a more substantial disc herniation, correlation of imaging studies with the clinical information has not been met. Given these findings, the requested ALIF at L4-5 and L5-S1 with posterior instrumented fusion is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 34-year-old female enrollee has requested emergency ambulance transportation as a result of her medical condition. Findings:  The physician reviewer found that this patient was transported from her residence to the Emergency Department. She reported a migraine headache that had commenced at midnight with associated nausea, vomiting and diarrhea. The patient was transported without any medical interventions or any change en route to the hospital. Ambulance transportation is medically indicated when all other means of travel are contraindicated. The patient must require services that only a fully equipped ambulance can provide. A patient is considered to be bedridden if she cannot remain seated in a wheelchair without assistance. A second issue, regardless of bed-confinement, is if the patient required medical services from the paramedics. This patient was not bed-ridden or oxygen dependent. She denied any life-threatening symptoms, such as chest pain, shortness of breath or gastrointestinal bleeding. Her physical examination was normal. The patient did not require or receive any medical treatment during transport. She did not require the services that only a fully equipped ambulance can provide. This patient could safely have been transported by means other than ambulance.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested for acute hospital eating disorder treatment for treatment of the enrollees major depression, severe, single episode, bulimia nervosa, and panic disorder without agoraphobia. Findings:  The physician reviewer found that depressed patients with suicidal ideation and plan, who also have significant medical comorbidities, history of physical abuse, and limited family and social support, are at elevated risk for suicide.  In such cases, psychiatric hospitalization is recommended by the American Psychiatric Association.  As noted by the American Psychiatric Association, determining the appropriate level of care requires consideration of the patients overall physical condition, psychology, behaviors, and social circumstances.  The interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  Considering the clinical presentation and documentation, coupled with relevant peer-reviewed medical literature, acute hospital eating disorder treatment level of care was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old female enrollee has requested speech therapy for the treatment of her autism. Findings:  The physician reviewer found that this patient meets general pediatric practice guidelines for continued speech therapy services. The services are requested to treat autism, which is considered an illness. Further, this patient is making progress toward specific goals as documented in the records provided for review. This patient requires the expertise of a skilled speech and language pathologist who is trained to facilitate patients optimization of speech and language skills, especially in those patients with autism. As noted by Paul in his recent publication, Children with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words. Aman agrees that the clinical data suggests that patients with autism spectrum disorders obtain lifelong gains in functioning as a result of early intervention with speech and language therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested authorization for a PET/CT scan for evaluation of her metastatic gastrointestinal stromal tumor. Findings:  The physician reviewer found that the previous Centers for Medicare and Medicaid Services (CMS) indications for PET scans did not include GIST. However, the National Oncologic PET Registry (NOPR) was developed in response to a CMS proposal to expand coverage for PET scans to include cancers and other indications not previously eligible for Medicare reimbursement. The diagnosis, initial staging, restaging, and monitoring of connective tissue and other soft tissue tumors are now listed as indications for PET scan. It has been shown that PET (PET/CT) is helpful in the staging and restaging of GIST and has an impact on clinical decision making for these patients. Tumor response to treatment with imatinib was best assessed with combined morphologic and functional imaging, specifically PET/CT. In addition, having the prior PET scans available for comparison increases the value of the recent examination. In this instance, a PET/CT would have been helpful in determining future care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Oxycodone 10 mg and Oxycontin ER 40 mg. Findings:  The physician reviewer found that currently, the Centers for Disease Control and Prevention (CDC) guidelines do not support the long-term use of opiates for chronic non-malignant pain. In the peer-reviewed medical literature, which studied women with chronic pelvic pain, the authors found poor outcomes with chronic opiate therapy. The authors noted that chronic opiate therapy is not recommended for patients with chronic pelvic pain. All told, the requested Oxycodone 10 mg and Oxycontin ER 40 mg are not medically necessary for treatment of this patients chronic pain. Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee has requested magnetic resonance neurography for evaluation of her left upper extremity neurologic symptoms.  Findings:  Three physician reviewers found that magnetic resonance neurography is used to better delineate nerves which are not well-evaluated on conventional magnetic resonance imaging. Magnetic resonance neurography has been studied to supplement diagnostic evaluations by electromyography and nerve conduction studies in patients with suspected peripheral nerve tumors, chronic compression, traumatic injury, post-irradiation neuritis, and pain syndromes where an anatomic lesion is suspected.  At this time, there is a lack of support in the medical literature demonstrating the superior efficacy of the diagnostic procedure at issue.  Large-scale, well-conducted studies are warranted.  Magnetic resonance neurography is not a first-line technique and should be used to supplement other diagnostic evaluations.  In this patients case, there is no indication that the patient had additional nerve conduction studies, electromyography or conventional magnetic resonance imaging.  Thus, the magnetic resonance neurography provided on the said date was not likely to have been superior over other available modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested abdominoplasty for treatment of her medical condition. Findings:  The physician reviewer found that abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions.  The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward.  In many cases, the tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths.  This maneuver repairs a diastasis recti which is a widening of the linea alba with separation of the rectus muscles.  In this patients case, given the flatness of her supraumbilical area, it is unlikely that her diastasis is related to her low back pain.  Abdominoplasty with or without diastasis recti repair is not a medically necessary procedure unless the excess skin is required to close an open wound.  This patients condition does not constitute an abnormal structure of the body.  The requested abdominoplasty would not be performed to either improve function and is not likely to improve her appearance.  All told, the requested abdominoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-month-old male enrollee has requested physical therapy for treatment of the enrollee, who has Down syndrome.  Findings:  The physician reviewer found that while the evidence demonstrates that standard of care recommends physical therapy for children with developmental delays associated with Down syndrome, the variability of developmental delays is wide.  As noted by Ranweiler, children with Down syndrome show varying degrees of developmental delays, and physical therapy is important for optimizing motor development. The physical therapy consultation provided used standardized testing to demonstrate developmental delay.  In addition, the provider documented specific developmental delays.  The primary physician documented that the patient was demonstrating developmental delays and had gross motor deficits.  All told, physical therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female has requested coverage for continued residential treatment from a specific date and forward for treatment of ther bipolar disorder, post-traumatic stress disorder, polysubstance dependence, and borderline personality disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  Clinical guidelines and patient placement criteria have been developed to assist in determining the appropriate level of care for patients.  The current guidelines support continued residential treatment in this clinical setting.  In this patients case, she required multiple acute admissions in the last year.  On the date in question, the patient was described as overwhelmed, confused, and depressed.  Further, she was in the process of a cross-taper from quetiapine to asenapine.  The patients pattern of substance abuse, impulsivity, and poorly developed coping skills necessitated continued residential treatment from the date in question and forward.  Considering the patients clinical presentation and history, continued residential treatment from the date in question and forward was and is medically indicated for the treatment of this patient.