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

Nature of Statutory Criteria/Case Summary: An enrollee has requested L5-S1 transforaminal lumbar interbody fusion surgery for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. Fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. According to Resnick and colleagues Numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. In addition, the evidence based medical guidelines do not support the use of discography as a stand-alone test to formulate treatment strategies for patients with low back pain (Eck, et al). In this case, the patient presents with chronic low back pain radiating into the lower extremities with bilateral foot numbness. Clinical exam findings documented sensory and motor deficits consistent with the L5 and S1 distribution, but there is no imaging evidence of disc herniation, central or foraminal stenosis at the L5-S1 level. Limited improvement was documented following left L5 and S1 selective nerve root blocks. A single-level discogram was reportedly positive at L5-S1, but outcomes have not been found to be consistently reliable for the low back based upon recent studies. This patients symptom generators have not been fully elucidated. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. In addition, a lumbar fusion adjacent to a two-level disc replacement would represent a hybrid-type complex surgical procedure for which there is a lack of significant long-term medical literature studies supporting its use. Therefore, the request for L5-S1 transforaminal lumbar interbody fusion surgery is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested surgery 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 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: An enrollee has requested reimbursement for inpatient mental health services from 5/11/18 to 5/14/18. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the enrollees severe depression. A review of the record indicates the enrollee was diagnosed with severe depression. The enrollee was admitted to a hospital on 5/2/18 due being a danger to self. During the period of 5/11/18 through 5/14/18, the provider noted the enrollee had continued to experience symptoms consistent with the reason for admission. On 5/15/18, the enrollee entered a residential program upon discharge from the hospital.The American Psychiatric Association guidelines note Admission to a hospital  may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. Given the severity of the patients suicide attempt and that, he remains with suicidal thoughts as well as helplessness and not attending to self-care, his risk remains high. Thus, admission for this patient from 5/11/18 through 5/14/18 was in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness, and is therefore medically necessary.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 14-year-old male enrollee have requested for a knee orthosis for treatment of the enrollees femoral fracture.   Findings:  The physician reviewer found that there is no mention or documentation of a problem that requires the use of a brace (such as knee joint instability).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric services from the date of service in question, forward. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. There was no evidence of suicidality. However, the patient remained unpredictable in her behavior, episodically aggressive, and unable to care for herself.  She was severely cognitively impaired.  She was oriented to person only, and she wandered.  She did not appear to have auditory hallucinations. It is unclear if she had visual hallucinations as she was observed to pick at objects in the air.  Her speech was nonsensical.  She had impaired attention and concentration, and poor insight and judgment.  She was receiving medication as needed for agitation. However, there were no medication changes after a later date.  By that time she had become more directable and her sleep had improved. Although she was still unpredictable, her aggressive behaviors had decreased.  At that point, inpatient level of care was no longer medically necessary. Therefore, acute inpatient psychiatric services from the date of service in question to the later date were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Specifically, acute inpatient psychiatric services from the date of service in question to the later datewere medically necessary, but not thereafter. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in geriatric psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested Roux-en-Y gastric bypass for treatment of his obesity.  Findings:  The physician reviewer found that this patient has a documented medical comorbidity of hypertension.  On the date in question, the documentation noted that he had completed 4 of 7 classes, but he had not undergone psychological evaluation.  He had not completed support group and seminar attendance or detailed journal recording of dietary intake. The available evidence suggests that completion of each component will increase the success of the bariatric surgery.  Most programs utilize a comprehensive preoperative approach for the benefit of the patient.  This patient has not completed these aspects, and he has not demonstrated suitability for the surgical procedure.  All told, the requested Roux-en-Y gastric bypass is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that tomosynthesis was approved by the Food and Drug Administration (FDA) for clinical use and by Centers for Medicare and Medicaid (CMS) for reimbursement.  The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocols was likely of more benefit to this patient than if the exam had been done with two dimensional technique alone. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers are board certified in diagnostic radiology and are 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a thirteen-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient has ongoing communication dysfunction. Continuity of her care by a developmental pediatrician has been documented since the age of four. Apparently, consistent recommendation of speech therapy has occurred since that time. The patient was extensively reassessed by qualified speech therapists with recommendation of hourly speech therapy sessions with specific goals of improvement within six months. The clinical situation is that of continuity of care documented from the age of four in a child with a congenital communication disorder. Documentation of medical necessity is abundant in the available reports. Speech therapy was and is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her morbid obesity.   Findings:  Two physician reviewers found that the patient meets generally accepted criteria for bariatric surgery. Laparoscopic sleeve gastrectomy is not investigational and is an appropriate primary treatment of morbid obesity. The laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension, hyperlipidemia, and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of obesity in the well selected patient such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested lumbar fusion surgery for the treatment of his low back pain. Findings:  The physician reviewer found that there is data to support the role of single level fusion surgery in improving the quality of life in patients with degenerative disc condition. Its use in single level cases is within the standard of good care. This patient has tried and failed physical therapy, and this has been documented. Due to the patients pain and one-level degenerative pathology, he is a candidate for the fusion procedure.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested autism behavioral intervention therapies (ABIT) 15 hours per week of therapy, 5 hours per month of supervision and 3 hours of treatment planning for treatment of his medical condition. Findings:  Two physician reviewers found that the services at issue were not and are not medically necessary for this patient. Pervasive developmental disorder, a subgroup of autism spectrum disorders (ASD), includes qualitative impairment in interpersonal communication as a core symptom.  There is a lack of peer-reviewed data demonstrating the efficacy of ABIT in this clinical situation. As such, the medical necessity of ABIT for treatment of this patients condition has not been established. The Health Plans authorization of monthly social skills group to assist with building interactive communication skills with peers is medically appropriate in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous lidocaine infusion for treatment of the enrollees new daily persistent headache.  Findings: Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  Intravenous lidocaine has been studied for the treatment of intractable headache in small pilot studies.  However, there is a lack of double-blinded, randomized, placebo-controlled prospective studies demonstrating efficacy.  Based on the lack of prospective randomized studies, the requested intravenous lidocaine infusion is not likely to be of greater benefit than other treatment alternatives.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 physician reviewers are board certified in neurology and are 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Actemra. On review of the medical documentation, this patient has evidence of biopsy-proven active chronic antibody mediated rejection (cAMR) with positive donor specific antibodies (DSAs). As cAMR is a major cause of graft loss, it is critical to treat the patients condition to prevent graft failure. As the patient is sensitized, and has a strong presence of DSAs, her chances of a second renal transplant are limited. Combination therapy with intravenous immunoglobulins and rituximab with or without plasma exchange is one treatment option. However, improved patient health outcomes have been shown with Actemra. Actemra is an IL-6 receptor monoclonal antibody that helps reduce DSAs in patients and preserve graft function. Actemra is an approach that has shown significant reductions in DSAs and stabilization of renal allograft function with few to no severe adverse events. Hence, Actemra is a preferred approach to stabilize the graft and improve survival rates for patients with cAMR. All told, Actemra is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Findings: The requested medication is likely to be more beneficial for treatment of the patient's 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 subspecialty certification in nephrology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in nephrology 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 44-year-old female enrollee has requested a continuous passive motion (CPM) device for treatment of her left knee pain.   Findings:  The physician reviewer found that the utilization of a CPM device status post arthroscopy for lateral meniscal tear and chrondomalacia has not been proven to improve functional outcomes in the rehabilitation of the knee following surgery. There is insufficient peer-reviewed literature supporting the use of the CPM device in this group of patients. As such, there is inadequate evidence to warrant the use of the CPM device in the patients post-operative recovery.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for individual therapy services once a week. The enrollee has a history of substance abuse that has worsened over the past years and is impairing his ability to function. The enrollee reports numerous attempts at rehabilitation, including a chemical dependency recovery program, but he believes he has such a strong compulsion to use that he is not able to remain sober longer than 60 days. The patient reports he does not have any available leave of absence time from work and he cannot make it to the chemical dependency recovery program on time. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The patients composite LOCUS score correlates Level III, High Intensity Community Based Services.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year, 8-month-old female enrollee has requested speech therapy for treatment of the enrollees expressive speech delay.  Findings:  The physician reviewer found that this young patient is cognitively normal and actually advanced in all her tested parameters except for the production of speech. When tested at 2-years, 6-months of age, she had a 15 word vocabulary and no phrases with skills at approximately a 1-year level. For this reason, she is likely to significantly benefit from speech therapy as supported by ample medical literature. Law and colleagues concluded in their meta-analysis of numerous medical studies that children with speech delay can be readily treated. In addition, Goorhuis-Brouwer and Kniff found that cognitively normal and delayed children with delayed speech are candidates for improvement with speech therapy. Further, Buschmann and colleagues addressed the accuracy of speech testing in a 2-year-old population and found that these patients are likely to benefit from speech therapy. All told, speech therapy is medically necessary to address this patients expressive language delay. The medical community standard for a two-year-old patient functioning at the level of a one-year-old peer includes speech therapy. This patient should receive two hours per week of speech therapy for six months followed by re-evaluation. If the patient demonstrates improvement, but still has significant expressive speech delay, speech therapy should be continued for an additional six months.
Appeal type: Medical Necessity
Decision: Overturned

A 72-year-old female enrollee has requested the Oncotype DX tumor assay for the evaluation of breast cancer.  Findings:  The physician reviewer found that the Oncotype diagnostic assays greatest utility is in indicating whether an individual patient falls into the low-risk category, or the high-risk category. Many authorities in breast cancer have accepted the validity of this testing and the applicability of the results in patients with low recurrence and high recurrence scores, which constitutes approximately 70% of all results. Based on this data, use of the Oncotype diagnostic assay is reasonable to risk-stratify a patient with node-negative, estrogen receptor-positive breast cancer, as in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old male enrollee has requested afatinib (Gilotrif) for treatment of his squamous cell carcinoma at base of tongue.  Findings:  Two physician reviewers found that this patient has recurrent metastatic disease.  There is sufficient support for the requested medication in this clinical setting.  There is preliminary evidence demonstrating the efficacy of afatinib in advanced squamous cell carcinoma of the head and neck.  There is a lack of alternative treatment options in this patients case.  Therefore, the requested afatinib is likely to be more efficacious than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested for inpatient care services for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that there is no acute depression and no acute/active suicidal ideation with plan were reflected in the clinical notes during the dates of service at issue.  No safety concerns were recorded in the noted. All told, the medical necessity of inpatient care services has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees receptive/expressive language delay. Findings:  The physician reviewer found that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. This patient has made significant progress in her receptive language skills with intervention and is likely to benefit from continued therapy.