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

A female enrollee requested admission into a skilled nursing rehabilitation facility for intensive physical therapy for medical treatment of her myasthenia gravis.  Findings:  The physician reviewer found that the patient has already undergone an extended stay in inpatient rehabilitation, where she had plateaued functionally. She did not tolerate more intensive therapies, primarily due to pain. Another stay at an inpatient rehabilitation facility would not be expected to produce significantly different results. Notably, she has not functionally ambulated for about a year, and her physician and physical therapist are recommending a power wheelchair for her mobility. For the reasons provided, admission into a skilled nursing rehabilitation facility is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 16-year-old female enrollee have requested Increlex for treatment of short stature.Findings:  The physician reviewer found that Increlex is FDA approved only for children with GH resistance syndromes. There were no clinical features identified that would support a GH-resistant phenotype.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Nutropin AQ Nuspin.The submitted records do not support the medical necessity of the requested medication. Essential diagnostic criterion for idiopathic short stature is a standing height below 2.25 standard deviations for age and gender. In this case, the patient has not met this essential diagnostic criterion for idiopathic short stature. They have not met the generally accepted diagnostic criteria for any United States Food and Drug Administration (FDA) approved indication for growth hormone therapy, including growth hormone deficiency. Their heights, bone ages, growth velocities, and growth patterns have been within normal variations and consistent with their twin birth status and their familial pattern of growth and development. Therefore, the requested Nutropin AQ Nuspin is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical implantation of an upper airway stimulation device for the hypoglossal nerve (CPT 64568 and 0466T). The records provided for review support a diagnosis of obstructive sleep apnea (OSA). The patients drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse with 100% collapse at the velum in the anteroposterior direction. There was significant improvement of the airway with jaw thrust. The patient has not been able to tolerate the CPAP device. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device. The patient is a candidate for the Inspire device given his intolerance to CPAP, anterior posterior collapse, no central apnea, and body mass index (BMI) of 29.28 kg/m2. The patients jaw thrust significantly improved the airway and there is no concentric collapse. Thus, the patient will benefit from the surgery. Accordingly, the requested surgical implantation of an upper airway stimulation device for the hypoglossal nerve (CPT 64568 and 0466T) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical implantation of an upper airway stimulation device for the hypoglossal nerve (CPT 64568 and 0466T) 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 reviewers 1, 2, and 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: Experimental/Investigational
Decision: Upheld

The parent of a 13-year-old male enrollee has requested biofeedback services for the treatment of the enrollees Aspergers syndrome, oppositional defiant disorder and mixed-receptive-expressive language disorder. Findings:  Three physician reviewers found that currently there is support in various peer-reviewed medical journals for the efficacy of biofeedback treatment for adult and pediatric migraines and tension cephalgia. Less supported in the literature and still investigational include the use of biofeedback for anxiety, hypertension and urinary incontinence. Currently, there is no indication in the medical literature that biofeedback is a proven, medically accepted, standard and current treatment in use in the medical and psychiatric communities for the treatment of Aspergers syndrome, oppositional defiant disorder and mixed receptive-language-disorder. Biofeedback is considered to be no better than standard treatment for this patients condition and is an investigational treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested a NESS H200 (upper extremity functional electrical stimulation device) and/or the NESS L300 (lower extremity functional electrical stimulation device) for the treatment of his left-sided hemiplegia secondary to stroke. Findings:  Two physician reviewers found that the patient was plateauing with standard physical therapy and occupational therapy. The evidence base for functional electrical stimulation is difficult to clarify due to industry sponsorship and involvement within trials which at the time of publication was not as clearly defined as it is now. Having said this, the available literature does support the use of functional electrical stimulation in stroke candidates with continued late residual deficits. The articles by both Peurala and Kimberley demonstrate improved learning and evidence for cortical changes associated with functional electrical stimulation. Price and colleagues also evaluated the effects on shoulder pain and noted a demonstrated improvement as well. All told, there is sufficient evidence to support the use of electrical stimulation in this case. The patient will require the NESS H200 and NESS L300 plus the requested physical therapy and occupational therapy by a provider trained in the implementation of these devices.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female with painful varicosities. In July 2004, the patient consulted a vascular surgeon who noted chronic venous insufficiency and symptomatic varicose veins on the right with chronic venous stasis. The vascular surgeon recommended sclerotherapy for treatment of the patients varicosities; however, the patient prefers to undergo surgical intervention. The Health Plan has denied authorization for vascular surgery on the basis that it is not medically necessary for treatment of the patients varicosities.Review of the submitted documentation does not demonstrate the patients condition warrants surgical intervention at this time. A limited ultrasound revealed no evidence of reflux; however, only the superficial veins (greater saphenous vein and lesser saphenous vein) were imaged. It appears further work-up may be in order. Additionally, there is no evidence the patient has undergone an adequate trial of conservative treatment. Although the submitted notes indicate the patient underwent a trial of compression stockings, there is no documentation regarding the results of the trial. Therefore, I have determined that the requested surgery is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage intensive outpatient program (IOP) services provided. The APA established a set of guidelines for determining the appropriate level of care for patients with eating disorders. Per medical guidelines, intensive outpatient programs (Level 2) are recommended for patients are:Medically stable; Self-sufficient or require minimal structure to  facilitate weight gain; Avoid compulsive exercising; Achieve and maintain a weight greater than 80-85% of normal;Exhibit no suicidality;Show fair to good motivation for change, adequate environmental support; Have no psychiatric co-morbidities requiring hospitalization or residential treatment, geographic proximity to treatment center; and Demonstrate the ability to control or eliminate purging.In this case, the patient began receiving IOP services.Laboratories drawn at that time and repeated a week later showed metabolic markers within normal range. There is no documentation suggesting suicidality or purging.  The patient was participating in group sessions indicating fair motivation.  By the 4th week, the patient no longer met APA criteria for IOP services. Daily notes indicate that the patient was able to control eating and was not purging. The patient was noted to have supportive parents. The patient did not require structured eating and did not need to be monitored for avoidance of excess exercise. Per the submitted records, the patient had improved greatly, was adhering to a meals program, had medications adjusted appropriately and was stable for transition to a lower-intensity outpatient treatment program. Therefore, in accordance with APA guidelines, intensive outpatient program (IOP) services were not and are not medically necessary for 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: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old female enrollee has requested surgical procedures (left hip multiple epiphysis drilling of the femoral head for decompression, left hip harvesting of bone graft for bone marrow cells, and left hip injection of autologous bone marrow cells) and associated hospital stay for treatment of the enrollees left hip avascular necrosis. Findings:  Three physician reviewers found the services at issue were likely to be more efficacious than other treatment options.  The procedure performed in this case was a decompression and bone grafting procedure.  Decompression was performed through drilling, which is a very common technique.  Bone grafting was performed by injection of harvested marrow cells.  This technique avoids the functional difficulties of harvesting the patients fibula as one alternative and avoids implanting foreign tissue.  There is sufficient support for the services at issue in this patients case.  Therefore, surgical procedures (left hip multiple epiphysis drilling of the femoral head for decompression, left hip harvesting of bone graft for bone marrow cells, and left hip injection of autologous bone marrow cells) and associated hospital stay were likely to have been of greater benefit than other available alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees sedative-hypnotic use disorder. Findings:  The physician reviewer found that the residential treatment center services were medically necessary, but not thereafter. Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. These basic pharmacokinetic and pharmacodynamic properties make alprazolam highly addictive and extremely difficult for patients to discontinue once it is started. Based on the concerning history of substance use, coupled with medical comorbidity and co-occurring psychiatric illness, this patient was at heightened risk for a complicated withdrawal syndrome which supports the detoxification component of the admission. However, although chemical dependency and psychiatric specialty services were indicated, and the patient more than likely benefited from the placement, the medical records do not demonstrate the medical necessity of the residential level of care. Upon admission, the patient was noted to be intelligent, diligent, spiritual and motivated for treatment. She did not have any medical issues that warranted 24-hour medical care. She did not have any acute psychiatric distress. She recognized that alprazolam had become a self-defeating intervention and wanted to develop healthy coping skills to address her anxiety. Further, there is a lack of evidence demonstrating a home environment unconducive to sobriety while she had a very supportive and involved family. Her mother, father, daughter and granddaughter all attended a family program, allowing the patient to consolidate the positive family visit, close-out services and solidify aftercare planning. Therefore, residential treatment center services have been established as medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections for both knees.  The American Academy of Orthopaedic Surgeons (AAOS) guidelines do not recommend hyaluronic acid for patients with symptomatic osteoarthritis, based on strong evidence. Numerous hyaluronic acid studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet the minimum clinically important improvement thresholds. There is a lack of support for Synvisc injections for both knees in this patients case. Therefore, Synvisc injections for both knees are not medically necessary for the treatment of this patient. 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 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: Upheld

The patient is an 85-year-old female with a history of mitral valve repair and embolic shower. This resulted in necrosis of the fingers on her right hand, and a below the knee amputation on the right and a metatarsal amputation on the left. She also has residual eschar. Her wounds are stable and require daily dressing (application of ointment). There is no evidence the patients wounds are green or draining or require packing. She undergoes a daily dressing change only. The wound on the patients buttocks does not exceed stage II and requires no more than a duoderm dressing. A request has been made for coverage for the patients continued stay at a skilled nursing facility after April 2006.  The Health Plan has denied the request on the basis the services are not medically necessary.Review of the submitted clinical evidence demonstrates the patients wounds were stable after April 2006. Her wounds can be appropriately addressed in a variety of settings: home, assisted living, or outpatient. The patients wound care and overall medical condition do not require daily inpatient care because her wounds are stable and only require application of medicinal ointment and clean dressing. There are no medical issues of high complexity involved in this case. Therefore, I have determined that continued skilled nursing facility services after April 2006 were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine and of the neck spine. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for the requested diagnostic procedure. There is a lack of support in the peer-reviewed literature supporting the requested diagnostic procedure in this clinical setting. The medical records submitted for review demonstrate evidence of back pain, however there is a lack of documentation showing the patient has had a trial of intensive anti-inflammatory medications as well as physical therapy and other conservative measures. Given the lack of conservative treatments tried and failed, the request for MRI of the lumbar spine and of the neck spine is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. Researchers state that MRI is appropriate as the next study after x-rays for patients following a fall or twisting injury when no fracture seen on a radiograph and there is suspected internal derangement. In patients with a fall or twisting injury who have focal tenderness, effusion, or inability to bear weight, radiographs should be the first imaging study obtained. If the radiograph shows no fracture, MRI is best for evaluating for a suspected meniscus or ligament tear, or the injuries from a reduced patellar dislocation. Parent and colleagues concluded that it is essential that the role of MRI be reconsidered in older patients and in those with osteoarthritis. This patient presents with persistent severe left knee pain following a twisting injury. The records document significant swelling, functional limitation with activities of daily living, and inability to bear weight on the left leg. Clinical examination findings have documented effusion, limited active range of motion, medial joint line and patellar tendon tenderness to palpation, and positive crepitus. X-rays of the left knee showed moderate degenerative joint disease. Patient has failed to improve despite reasonable conservative treatment, including activity modification, NSAIDs, corticosteroid injections, and bracing. Given the patients history of injury, persistent left knee pain and dysfunction, radiographic evidence of moderate osteoarthritis, and failure of conservative treatment, current evidence based medical literature and guidelines supports a left knee MRI. Therefore, the requested MRI of the left knee is medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested neck surgery (insertion of an artificial intervertebral disc) for treatment of his medical condition.  Findings:  Three physician reviewers found that there is a lack of sufficient data to adequately assess the performance of total disc replacement. Specifically, there is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Moreover, in this case, the patient has severe cervical spondylosis with foraminal impingement at the index level chosen for treatment. The standard procedure would be a single level anterior cervical discectomy and fusion. The use of a total disc arthroplasty in the setting of severe spondylosis with multilevel bilateral foraminal compromise by disc osteophyte complex and degenerated disc remains controversial. Particularly when used adjacent to a severely spondylotic level. Thus, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing.  Two reviewers are board certified in neurological surgery 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.