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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee have requested reimbursement for hospital bed (Safety Sleeper enclosed bed) with accessories purchased.Sleep is an essential part of life, health, and wellbeing, and is a crucial part of mental health/behavior and immune function. Typically developing children who do not get adequate sleep have difficulty with executive functions such as problem solving and concentration, difficulty with self-control and coping, and increased risk of mental health problems. A study found states that although cognitive abilities may be different in children with developmental disabilities such as Smith-Magenis syndrome, adequate sleep in a safe environment allows such children to optimize their abilities and function at their highest level. Additionally, a study found states that the use of enclosure beds is a reasonable intervention in children whose behavioral challenges can impact safety. In this case, as part of this patients genetic condition, she awakens frequently at night. The patient was at risk of significant injury if in a bed with siderails, and she was at great risk of elopement if she was not contained in a safe environment. In the absence of some type of restraint system or an all-night aide to monitor her activities, there were no alternatives to a specialty bed to maintain her safety and allow her to get the sleep that was medically necessary for her health and behavior. The requested Safety Sleeper bed was ideal because it provided a safe sleep environment as a soft enclosure to prevent injury and elopement. Therefore, the hospital bed (Safety Sleeper enclosed bed) with accessories purchased was medically necessary for the treatment of the patients medical condition.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 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 an enrollee has requested inpatient hospitalization for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  According to article researchers regarding care of postoperative cystic fibrosis (CF) patients Postoperative pain management is critically important in the CF patient population. Pain control is especially important in patients with CF to encourage coughing, deep breathing, and minimize pulmonary complications. Patients should have early access to chest physical therapy and early activity and mobilization as well. Patients requiring home oxygen or noninvasive positive pressure ventilation, such as [bilevel positive airway pressure] (BiPAP), must be monitored carefully postoperatively for respiratory failure as evidenced by increased work of breathing, retention of carbon dioxide, and hypoxemia. Patients requiring BiPAP should have immediate access to their equipment. Patients with moderate to severe pulmonary disease should be admitted for overnight monitoring of their recovery from surgery and anesthesia. This patient has extenuating circumstances that requires a higher level of care. The patient has a cardiac condition that puts him at additional risk from anesthesia during the procedure and following the procedure from pain medication. Pain medication, especially given through IV can suppress the patients respiratory drive and cough and exacerbate his pulmonary condition. All told, inpatient hospitalization was medically necessary in this clinical setting.  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 and pediatric cardiology 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 rituximab for treatment of his medical condition.  Findings: Two physician reviewers found that rituximab is likely to be more beneficial for treatment of the patients medical condition than other modalities. This patient has been treated with the standard treatment options for minimal change nephrotic syndrome and focal segmental glomerulosclerosis (MCNS/FSGS) including steroids, cyclophosphamide and cyclosporine with frequent relapses of nephrotic syndrome. The case study by researchers concluded that rituximab may be effective treatment for refractory steroid resistant nephrotic syndrome with FSGS. Based on the reasons provided, rituximab is likely to be more beneficial for treatment of the patients medical condition than any available modalities.  Final Result: Two reviewers determined that the medication at issue was and 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: One reviewer is board certified in pediatric nephrology and is actively practicing. Two physician reviewers are board certified in internal medicine with sub-specialty certification in nephrology 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: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that Botox is not a first-line therapy for migraine headache, there is adequate literature supporting its use for patients with chronic or intractable headaches. As noted by Tiesler in a phase 2 study of patients treated with Botox and no additional therapy, the patients, had significantly more pain-free days than those treated with placebo. They also required less frequent administration of headache medicines.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal chromosomal aneuploidy (CPT 81420) genetic testing. The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin regarding non-invasive prenatal testing. The ACOG bulletin noted that cell-free DNA screening evaluates short segments of DNA in maternal blood and can be used to screen for a variety of fetal conditions. The ACOG promotes aneuploidy screening or diagnostic testing for fetal genetic disorders, regardless of maternal age. The patient in this case underwent testing while pregnant consistent with the ACOG recommendations. Given this support, the fetal chromosomal aneuploidy (CPT 81420) genetic testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the fetal chromosomal aneuploidy (CPT 81420) genetic testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the fetal chromosomal aneuploidy (CPT 81420) genetic testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in obstetrics and gynecology and are actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services. Findings:  The physician reviewer found that IOP services were and are medically necessary for treatment of this patients behavioral health issues. The patient presents with no risk of harm behaviors. The patient has demonstrated a deterioration in his functional status and severe difficulties functioning in relationships with his peers, adults, and family. The patient has minor comorbidity with a history of substance use and psychiatric issues. The patients recovery environment is moderately stressful. However, the patients recovery environment is supportive. The patient has made minimal progress in treatment. Therefore, the composite score correlates with intensive outpatient services. Given these findings, the IOP services provided were and are medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty certification 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: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested 108 hours per month of applied behavioral analysis (ABA) therapy and 16 hours per month of BCBA services for treatment of the enrollees autism.  Findings:  The physician reviewer found the medical literature strongly supports applied behavioral analysis (ABA) therapy for the treatment of young children with autism. The medical literature clearly emphasizes that the effectiveness of ABA therapy depends on early diagnosis and early initiation of therapy. In this case, this 10-year-old patient has received many years of ABA therapy initiated at a relatively early age with limited improvement in behavior and socialization. Although it is medically necessary for the patient to continue ABA therapy, the frequency of therapy requested by the patients parent is not medically necessary, as it is not likely to result in clinically significant improvement in the patients functional status. The 60 hours of ABA therapy per month and 6 hours of BCBA services per month are medically reasonable and appropriate for this patient who presents with delays in language development, adaptive and social skills. The medical necessity of the requested 108 hours per month of ABA therapy and 16 hours per month of BCBA services has not been established based upon the submitted clinical documentation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was hospitalized for treatment of DKA and its sequelae. Her documented medical history was significant for having type 2 diabetes mellitus and headaches. The patient reportedly presented to her primary care providers outpatient office. A diagnosis of urinary tract infection was reportedly determined. Laboratory testing was performed, and the patient was subsequently directed to the emergency department. The patient was admitted for inpatient care. The treating provider notes indicated that the patient had been diagnosed with DKA, an acute urinary tract infection, diarrhea, high anion gap metabolic acidosis, hyponatremic dehydration, elevated blood pressure and heart rate, and a migraine headache. In this case, the records do not support the medical need for inpatient care. Some factors and circumstances can complicate DKA treatment and worsen outcomes, necessitating both emergent treatment and hospitalization, such as evidence of shock, certain arrhythmias, or an insufficient response to initial treatment. In this patients case, there was no submitted documentation or suggestion that such issues played a significant role, necessitating inpatient care. Although emergent treatment and monitoring was required initially to prevent the development of potentially life-threatening complications from her condition, inpatient services were not medically necessary. The patients sodium had normalized, white count had normalized, urinary tract infection was mild, glucose was coming down, and the patient was hemodynamically stable. As such, although additional monitoring may have been needed, this could have been accomplished in an observation setting rather requiring inpatient admission. Therefore, inpatient hospital services were not medically necessary for the treatment of this patient. 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 internal 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: Overturned

A 44-year-old female has requested an abdominoplasty and medial thigh lifts for treatment of her excess abdominal and thigh skin.   Findings:  The physician reviewer found that obesity can be considered a disease, of which correction should be considered in a similar regard. Obesity correction is known to create significant functional deficits. This patient is documented to have a functional deficit of recurrent infections as a direct result of the overlapping tissue. She is noted to have undergone treatment with antifungal medications. The records indicate the area of concern directly contributing to this functional deficit is related to the areas around the pubis and medial thigh area and not the upper or lower abdomen. A medically necessary procedure is one that should attempt to correct a functional problem. The American Society of Plastic Surgeons (ASPS) states that, When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. In addition, only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature. This patients medical records demonstrate such a rare circumstance that the pubic area and confluence with the medial thigh is the source of the functional deficit. Common functional problems associated with an overhanging pannus or skin redundancy are described as causing disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. However, this patients records do not demonstrate that the upper or lower abdominal skin folds are a significant source of her functional deficit. Abdominoplasty includes treatment of the upper abdomen and muscle plication. The medical records do not support that a functional deficit has been established by the upper abdominal overlap. Based on the photographs, the lower abdomen does not appear to be contributing significantly to this condition. The upper and lower abdomen does not appear to have created a significant overlap. All told, the requested abdominoplasty is not expected to offer more than a minimal improvement or improve the patients functional deficit. Overall, the medial thigh area at its confluence with the pubis appears to be the source of the functional deficit. This area of overlap appears to be an area that could be significantly improved in the appearance as well.  In summary, treatment of the upper and lower abdomen with abdominoplasty should not be authorized, whereas the medial thigh lift is reconstructive in nature and medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service 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: All three 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: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her  history of left breast pain. Findings:  Two physician reviewers found that in this patients case, the diagnostic procedure at issue was not likely to have been more effective than other methods of evaluation.  There is a lack of support for the breast MRI performed on the date indicated.  The records do not indicate a breast lump or nipple discharge.  The documentation does not state that the patient has a personal or family history of breast cancer.  Based upon the clinical notes, there is no evidence that the patient has an increased lifetime risk of breast cancer which would necessitate a breast MRI.  The records note breast pain and dense breasts on mammogram, and these are not indications for breast MRI.  All told, the superior efficacy of the breast MRI performed on the date indicated has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the balloon sinus ostial dilation procedure performed.  Findings:  The physician reviewer found that Balloon sinuplasty is a U.S. Food and Drug Administration (FDA) approved treatment for well selected patients with chronic sinusitis. However, this patients CT scan did not reveal significant disease that would be amenable to treatment with balloon sinuplasty. In addition, the patient had not been adequately treated with proper medical therapy including a longer course of antibiotics and nasal steroids prior to undergoing balloon ostial dilation. Accordingly, the balloon sinus ostial dilation procedure performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the procedure at issue was 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 otolaryngology 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 patients caregiver has requested reimbursement for intensive outpatient program (IOP) level of care services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients composite score is consistent with community-based services, the minimum being intensive outpatient therapy. Given these findings, the IOP services were medically necessary for treatment of this patient.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 psychiatry with subspecialty certification 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.