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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment services provided for disputed dates  and prospective authorization and coverage for residential treatment services. Findings:  The physician reviewer found that as noted in the practice guidelines, RTC is considered the highest level of psychiatric care available. Medical necessity guidelines indicate that psychiatric symptoms must be present to the degree that this level of care is needed. The available records do not indicate that this patient had severe psychiatric symptoms but rather continued substance use and associated depressive symptoms due to substance use. The progress notes indicate that the patient was cooperative in treatment. The patient used substances throughout IOP treatment and has failed RTC in the past as well as outpatient treatment on numerous occasions. It appears that the desire for RTC is due to isolation from substances for brief sobriety. The patients family appears to be engaged in substance use and this has been a detriment to the patients sobriety. However, it is unlikely that RTC level of care services will have any benefit on the patients substance use due to numerous failures of this type of treatment as well as apparent minimal commitment to behavioral change on the part of the patient or family. Further, repeated RTC treatment is not indicated or evidence-based. Family therapy is therefore essential to the patients success in the future due to the patients family systems issues. All told, residential treatment services provided and  prospective coverage for residential treatment services were not and are not medically necessary for treatment of this patients medical condition. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision of gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although this patient remains morbidly obese, revisional bariatric is not medically necessary.  This patient was unable to document the necessary behavioral, dietary and lifestyle changes that were felt to be necessary by the multidisciplinary team to warrant success from a second or different bariatric procedure.  The current medical evidence does not support the requested services in this clinical setting.  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 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 parent of a 12-year-old male enrollee has requested social skills training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that social skills deficits are a pervasive and enduring feature of autism spectrum disorders (Bellini and colleagues). Social skills deficits have been linked to deleterious outcomes such as social isolation, social anxiety and depression. This young patient has a history of anxiety and depression with hospitalization following a suicidal gesture. He was treated as an inpatient following a 5150 hold with reported suicidal ideation related to difficulties with school. The requested services for social skills training are therefore medically necessary in order to aid the patient in improving his social interaction skills and his ability to effectively communicate.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 1-year, 10-month-old female enrollee has requested speech therapy twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient is intellectually normal yet her expressive speech has shown no significant development. She is now nearly 2 years of age and should have a vocabulary of at least 50 words and should be initiating 2-word phrases. Both speech pathologists reported that the patient could not imitate or produce sounds. Overall, the formal testing has clearly demonstrated language delay in this patient. She is functioning at a severe to profound delay in her speech development but her language delay does not seem to be related to an underlying cognitive dysfunction. The delay is directly related to failure of normal brain maturation and is a congenital defect. In the medical literature, Law and colleagues reported that children with speech delay can be readily treated while Prelock and colleagues discussed the evaluation and successful therapies of speech delayed children. These findings were confirmed in the meta-analysis of multiple medical journal articles from Goorhuis-Brouwer and Kniff who specifically addressed the needs of speech-delayed children. The authors concluded that young, cognitively normal patients, are ideal candidates for successful speech therapy. Consistent with these recommendations for intervention the requested speech therapy is medically indicated for this patient. The medical community standard for a two year-old non-speaking child is speech therapy. The recommendation is for two hours per week for six months followed by speech re-evaluation. If the patient demonstrates improvement, but still has significant expressive speech delay, speech therapy should be continued for another six months.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 38-year-old female stated to have weighed nearly 500 pounds prior to gastric bypass surgery in November 2004. The patients physician and her bariatric surgeon have suggested the patient needs to be evaluated for panniculectomy by a plastic surgeon. The Health Plan has denied authorization for a consultation with a plastic surgeon citing a lack of medical necessity.The submitted materials include photographs of the patient, medical records, and a letter from the patients bariatric surgeon. These clearly demonstrate that the patient has a significant pannus hanging well below the pubis and the potential for intertrigo. However, there is no definitive evaluation by a plastic surgeon familiar with this significant deformity to assess medical necessity. Based upon the information provided, it is highly likely the patient will require a panniculectomy at some point to relieve her back pain as well as the potential for intertrigo. The patient should be evaluated by a plastic surgeon to determine if surgical invention is medically appropriate and indicated at this time. Therefore, I have determined the requested consultation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for anterior/posterior lumbar fusion surgery. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document obesity, chronic back pain and ill-defined lower extremity symptoms which are not consistent with lumbar radiculopathy. The records do not document vascular studies to rule out vascular claudication. He has not failed conservative management. There is a lack of correlation of his imaging with his clinical condition. He had an abnormal MRI with stenosis, but there was no evidence of nerve root compression. The current medical evidence does not support the requested services in this clinical setting. Therefore, the requested anterior/posterior lumbar fusion surgery is 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of peripheral nerve stimulator. This patient presents with a history of chronic low back pain. The provider noted that the patients pain is likely due to history of L1 pathologic fracture secondary to metastatic cortical adrenal carcinoma status post L1 transpedicular decompression and T10-L5 fusion. The patients pain is described as multifactorial in nature including reaction to hardware. The provider charted that the patient responded well to diagnostic erector spinae blocks and paravertebral nerve blocks with temporary relief. On review of the current peer-reviewed medical literature, there is a paucity of studies demonstrating the long-term safety and efficacy of peripheral nerve stimulation in the treatment of patients with low back pain. Specifically, there is a lack of studies showing that peripheral nerve stimulation yields superior patient health outcomes as compared to standard available therapies. Cohen and colleagues reported on nine patients who reported improvement with percutaneous peripheral nerve stimulation in function, as evidenced by clinically and statistically significant reductions in pain, disability, and pain interference. Gilmore and colleagues have reported similar preliminary findings. However, the data was not obtained in prospective randomized controlled trials to support the routine use of percutaneous peripheral nerve stimulation for treatment of this patients low back pain. All told, the requested implantation of peripheral nerve stimulator is not 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 implantation of peripheral nerve stimulator is 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 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: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain 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: Upheld

A 37-year-old woman at 22 weeks gestation with a twin pregnancy and a beta-thalassemia trait diagnosis requesting authorization for treatment of her anemia with Procrit.   Reviewers Findings:The reviewing physician found there is very little experience reported in the use of recombinant erythropoietin in pregnancy, and even less in its use for the anemia of thalassemias. Clearly the efficacy and safety of recombinant erythropoietin use for thalassemia during pregnancy is not established and cannot be considered medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Stelara 90 mg every four (4) weeks. American College of Gastroenterology (ACG) clinical guidelines state that ustekinumab (Stelara) should be given for moderate-to-severe Crohns disease patients who failed previous treatment with corticosteroids, thiopurines, methotrexate, or anti-TNF inhibitors or who have had no prior exposure to anti-TNF inhibitors (strong recommendation, high level of evidence). The guidelines explain that among patients who are initial anti-TNF therapy responders, approximately one-third subsequently lose their response to therapy or become intolerant to therapy (secondary nonresponders). These secondary nonresponders can either escalate dose of their current medication, switch to another anti-TNF agent, or switch out of class (to an anti-integrin (natalizumab or vedolizumab), anti-IL-12 / 23 (ustekinumab), or to a novel mechanism. In this case, the patient has a history of active Crohns disease, primary sclerosing cholangitis, and diffuse large B cell lymphoma (DLBCL). His DLBCL makes a TNFi contraindicated. Furthermore, the submitted records demonstrate extenuating circumstances given the patients recent DLBCL, the need to avoid certain medications, the patients partial response to Stelara at standard dosing, the COVID-19 pandemic, and the minimal cancer risk with this medication. Under these circumstances, the requested medication, Stelara 90 mg every four (4) weeks, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, 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 authorization and coverage for cervical artificial disc procedure for treatment of her medical condition. The physician reviewer found that according to the documentation submitted for review, this patient has degeneration of multiple cervical levels on magnetic resonance imaging and has been treated with multiple conservative measures. However, a one-level cervical total disc replacement is contraindicated because the patient has MRI evidence of more than one level of cervical degeneration. Moreover, the surgery is not likely to relieve the patients neck pain. Therefore, the request for cervical artificial disc is not likely to be more beneficial for the patient's medical condition than any other available standard therapy. Final Result: The reviewer determined that the requested procedure is 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:  The physician reviewer found that rhe 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 authorization and coverage for the LINX procedure (CPT 43284). Lipham and colleagues note in a multicenter, prospective, single-arm study of 44 patients, that sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits without safety issues, as demonstrated by reduced esophageal acid exposure, improved quality of life related to gastroesophageal reflux disease (GERD), and cessation of dependence on proton-pump inhibitors (PPIs), with minimal side effects and no safety issues. However, Sheu and Rattner note that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remains to be determined. Bauer and colleagues note the possibility of adverse events, including erosion through the esophagus. While the U.S. Food and Drug Administration (FDA) approves the use of the LINX Reflux Management System for patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite medical therapy for the treatment of reflux, based on current evidence and medical literature, the technology has not met a consensus opinion or recommendation by medical societies and governing organizations. The requested service has not been rigorously tested in randomized controlled trials against alternative therapies and therefore, it is not possible to establish an individualized benefit in this case. Due to the lack of consensus among national and local health care providers, there are no set standard protocols regarding the terms and conditions for use. Therefore, a LINX procedure (CPT 43284) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested LINX procedure (CPT 43284) is 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 requested service is 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, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection series in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of long-term relief from viscosupplementation of both knees with Orthovisc for the last 10 to 15 years. Furthermore, the options are limited, with the alternative being bilateral total knee arthroplasties. Thus, the requested Orthovisc injection series in both knees is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested acute inpatient psychiatric hospitalization services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not in withdrawals.  She was medically stable. She was not psychotic.  She had no delusions or hallucinations in any modality.  Per the medical records, the patient was not homicidal, violent or aggressive towards others.  She did not require 24-hour medical and nursing supervision on an inpatient level of care.  Thus, acute inpatient psychiatric hospitalization services was not medically indicated 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 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.