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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a custom quickie 2 ultralight wheelchair with smartchair accessories (E0986-manual wheelchair accessory, push activated power assist, each; K0005-ultralightweight wheelchair; E2218-manual wheelchair accessory, foam propulsion tire, any size, each; K0040-adjustable angle footplate, each; K0108-wheelchair component or accessory, not otherwise specified; E0973-wheelchair accessory, adjustable height, detachable armrest, complete assembly, each; E0971- manual wheelchair accessory, anti-tipping device, each; E1028-wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick , other control interface or positioning accessory; E2606-positioning wheelchair seat cushion, width 22 inches or greater, any depth; and K0108-wheelchair component or accessory, not otherwise specified) for treatment of the enrollees Ehlers-Danlos syndrome. Findings:  The physician reviewer found that The documentation provided do not support the medical necessity of the requested equipment and accessories in this clinical setting. The records indicate that the patient has various symptoms and conditions, including fatigue and various pains.  The patient has had difficulty with ambulation at times. A scooter and a manual wheelchair with power assist have been recommended. The scooter has been declined by the patient/family due to accessibility issues within the home and transportation problems. The records, overall, do not indicate that the patients mobility related activities of daily living needs in the home could not be adequately met with a standard lightweight manual wheelchair under caregiver distant supervision. Notably, the patient is reported to have difficulty with prolonged sitting. The records do not support the medical necessity for the ultralight manual wheelchair with the accessories. Final Result: The reviewer determined that the requested equipment and accessories 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested residential treatment facility (RTC) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that during the period at issue, the patients pulse and blood pressure remained within the normal range. Her weight was stable and consistent, with a BMI of about 20. The group therapy notes continued to document her active and appropriate participation. The progress notes also indicated her bright mood, active participation, compliance with her meal plan, and good progress. Further, her family was very supportive and cooperative. She had demonstrated that she was using her coping skills to address her anxiety about weight gain. As such, the medical necessity of the RTC services at issue has not been established in this patients care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a neurosurgery consultation for evaluation of his medical condition. Findings: The physician reviewer found that the records provided for review document that this patient does have disc degeneration and scoliotic deformity by history. A consultation with a board certified neurosurgeon is therefore indicated to assess the patient for appropriate non-surgical or surgical treatment options. As noted by Issack and colleagues, nonsurgical management consists of nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy, is indicated. Given these findings, the requested neurosurgery consultation is medically necessary for evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in neurological 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

The representative of a deceased 64-year-old male enrollee has requested for skilled nursing facility (SNF) services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient was in worse condition in terms of PT and OT performance. He regressed from contact guard assist with PT to minimum assist of two and from moderate assist with OT to maximum assist. However, the patient was found to have a stage III decubitus, which required daily skilled nursing.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested a neurological exam by a specialist for treatment of her ataxia. Findings:  The physician reviewer found that the patient was diagnosed and has previously been followed at an ataxia specialty clinic by a team that is familiar with this disease. Although the Health Plan states there is no treatment for ataxia which requires follow-up by a neurologist, there are treatments available for symptomatology associated with ataxia. In fact, this patient is on levetiracetam as a specific treatment of ataxia which was initiated by a neurologist at the ataxia specialty clinic. The use of this agent is supported by reports of efficacy in several open-label studies. The patients care requires treatment of the multiple associated symptoms that are unique to hereditary ataxias and a specialist in ataxia is best equipped to evaluate the patient and make recommendations regarding her ongoing treatment. Thus, a neurological exam by a specialist is clinically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure (HCPCS C9752). A review of the recent medical literature reveals that the Intracept procedure is a safe and effective treatment modality for patients with chronic vertebrogenic pain. In this patients case, there is evidence of vertebrogenic pain caused by vertebral endplate degeneration with cortical bone damage and subchondral bone inflammatory reaction and edema at the L5-S1 level. Vertebrogenic pain is often the cause of low back pain transmitted by the basivertebral nerve. As noted in the medical literature, radiofrequency ablation of the basivertebral nerve can lead to a thermal injury of nerve tissue and relief of pain (De Vivo, et al.). Khalil and colleagues concluded that minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of functional and pain relief at three-month follow-up in patients with chronic low back pain. This patients low back pain has failed to improve with adequate non-invasive treatment including physical therapy and medications, as well as injection therapy. The patients low back pain is interfering with his ability to perform activities of daily living. In addition, the patient has declined invasive surgery with the exception of minimally invasive procedures. In light of the foregoing, the requested Intracept procedure (HCPCS C9752) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Intracept procedure (HCPCS C9752) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested for IVIG therapy for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the patient has multiple sclerosis and has progressed on Copaxone and IVIG.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Norditropin FlexPro 10 mg/1.5 mL growth hormone. Findings:  The physician reviewer found that This patient presents with a history of short stature in the setting of normal findings on two growth hormone provocative tests and decreased growth velocity. The patients provider has recommended treatment with growth hormone therapy. Based on the available documentation, this patient does not meet the criteria for a U.S. Food and Drug Administration (FDA) approved indication for growth hormone therapy, including idiopathic short stature. In addition, the patient does not meet the requirements for treatment with growth hormone therapy per the Drug and Therapeutics, and Ethics Committees of the Pediatric Endocrine Society. Although the patients recent growth velocity was lower than expected for early-to-mid puberty, this observation alone does not support treatment with growth hormone therapy. The current recommendations for the evaluation of growth failure in young female patients includes karyotype to exclude mosaic Turner syndrome and direct measurements of both biological parents to best estimate the patients midparental target height. Given these findings, the requested Norditropin FlexPro 10 mg/1.5 mL growth hormone is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 pediatrics with subspecialty certification in pediatric endocrinology 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 53-year-old female enrollee has requested a PET scan for evaluation of her breast cancer.  Findings:  The physician reviewer found that over the last decade, there have been many studies showing the efficacy of PET scan for staging breast cancer.  In October 2002, the Centers for Medicare and Medicaid Services (CMS) approved PET scans for breast cancer staging/restaging of local/regional recurrence or distant metastases. PET scan has been shown to be more sensitive and specific than CT scan for detection of mediastinal and internal mammary lymph node metastases. Furthermore, PET scan has been shown to be more sensitive, specific, accurate, and have better positive and negative predictive values than conventional imaging for detecting local recurrence or distant metastases. PET scan has proven to have a significant impact on the care of breast cancer patients, influencing both clinical staging and management.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested intensive outpatient program services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient continued to demonstrate active eating disorder behavior.  There was little supervision of her behavior outside of the program by her family.  Although the patient made some progress in identifying triggers of boredom and loneliness, the treatment plan was not changed to accommodate for her lack of progress.  Laboratory testing was only marginally out of range and her vital signs were stable.  Continuing treatment at this level of care was not expected to yield further improvement.  All told, intensive outpatient program services were not and are not medically indicated 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. To objectively determine if the patient meets criteria for the appealed level of stay, the Level of Care Utilization System (LOCUS) criteria is used. This is an accepted, national standard for determining the appropriate level of care for adults. The patients risk of harm based on the LOCUS criteria is a 2 which correlates to low risk of harm. The patients functional status is a 3, moderate impairment.  The patients medical/addictive/psychiatric comorbidity is a 3 which correlates to significant comorbidity.  The patients recovery environment is a 3, moderately stressful environment. The patients level of support is also scored a 3, limited support.   The patients treatment history is scored a 3 which correlates to equivocal response to treatment and recovery. The patient was in an intensive outpatient program previously but relapsed. The documentation submitted did not mention other prior treatments. The patients engagement and recovery status is scored a 3, limited engagement and recovery. The patient is attentive and engaged during treatment. However, the patient does not feel that she is an addict and will not commit to complete sobriety. It appears that she remains ambivalent about her desires to stop using alcohol. The patients total scored is 20. Based on the LOCUS criteria, the patient would meet criteria for a partial hospitalization program (PHP) and not RTC. The patient requires treatment for her alcohol use disorder, but the treatment can be performed at a PHP level of care. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraosseous ablation of the basivertebral nerve using the Intracept procedure. Current medical literature supports the functional benefits from the requested procedure and efficacy based on long-term clinical outcomes. Medical literature shows that patients with chronic low back pain treated with basivertebral nerve ablation sustained clinical improvements in function and pain with high responder rates at a mean of 6.4 years following treatment. Medical literature further concluded that basivertebral nerve ablation is a durable, minimally invasive treatment for vertebrogenic chronic low back pain. Therefore, the intraosseous ablation of the basivertebral nerve using the Intracept procedure is likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure  is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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:  An enrollee requested bilateral breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Per the medical literature, breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  The medical records noted heterogeneously dense breast tissue.  Thus, the addition of breast tomosynthesis to screening mammography was likely to have been more beneficial to the patient than digital screening without added tomosynthesis.  Therefore, the medical records demonstrate the superior effectiveness of bilateral breast tomosynthesis performed.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: Reviewers 1, 2, and 3 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued inpatient antifungal intravenous treatment (Diflucan intravenous) for treatment of the enrollees medical condition.Findings:  The physician reviewer found that There is a lack of support in the medical literature for the requested services in this clinical setting. The patient had reported that she needed to remain in the hospital for this therapy and that she was allergic to oral antifungals but not to intravenous ones. However, the standard recommendation for catheter associated fungal bacteremia in most hosts is an oral antifungal and catheter removal.  In this clinical setting, the standard of care would be removal of catheter and treatment with an oral antifungal.  The blood culture that grew candida also grew a coagulase negative staphylococcus which suggests the culture represents contamination with skin flora and not true catheter associated infection. The intravenous administration of an antifungal in this patients case is not supported by standard practice. In addition, treatment in the acute care setting is not clinically indicated for this patient. All told, inpatient antifungal intravenous treatment (Diflucan intravenous) at Providence Little Company of Mary Medical Center is not medically necessary for treatment of this 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 internal medicine with sub-specialty certification in infectious disease 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: The patient has requested authorization and coverage for CPT code 21121 (genioplasty sliding osteotomy single piece) done in conjunction with the approved procedure CPT code 21196 (reconstruction of mandibular rami and/or body, sagittal split). The submitted documentation fails to demonstrate the medical necessity of the requested services. The requested CPT code 21121 (genioplasty sliding osteotomy single piece) does not have a supported clinical role in treating this patients occlusion or temporomandibular joint disorder. There is a lack of peer-reviewed medical literature demonstrating that genioplasty is beneficial for treating malocclusion or temporomandibular joint disorder. Thus, CPT code 21121 (genioplasty sliding osteotomy single piece) is not medically necessary for the treatment of this patient. Based on the submitted documentation, the patients condition represents an abnormal structure of the body. Per the submitted records, this abnormal structure of the body is caused by developmental abnormalities. The abnormal structures which involve the mandible, maxilla and the dentition are mainly a result of developmental forces. Additionally, CPT code 21121 is not likely to improve function. The patients chin is mildly retruded, but this does not impair her oral or facial function. The requested CPT code 21121 is not likely to provide more than a minimal improvement in the appearance of the patient. Per the records, the amount of retrusion is a few millimeters, which constitutes a very minor cosmetic defect. Therefore, CPT code 21121 (genioplasty sliding osteotomy single piece) is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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.