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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Stelara injections for treatment of the enrollees palmar/plantar psoriasis. Findings: The physician reviewer found that  based on a combination of evidence and guidelines, the recommended therapy for treatment of this patients medical condition is treatment with non-steroidal anti-inflammatory drugs followed by disease-modifying antirheumatic drugs (DMARDs), if the disease is still active (Ritchlin, et al; Gossec, et al). In patients whose joint pain does not improve after three months of treatment with methotrexate (MTX), most recommend treatment with leflunomide. The current consensus among experts is that anti-tumor necrosis factor (TNF) inhibitors should be used after the failure of an adequate therapeutic trial of one traditional DMARD. The TNF agents that are approved for psoriatic arthritis are etanercept (Enbrel), adalimumab (Humira), infliximab, and golimumab.  In those psoriatic arthritis patients who do not respond to two different TNF inhibitors or have a contraindication to anti-TNF therapy, the use of ustekinumab (Stelara) is recommended. In this case, the patient has failed MTX due to elevated liver function tests. The medical literature recommends failure of two anti-TNF agents prior to trying another agent. She has tried Enbrel, a receptor antagonist, which was ineffective. However, the submitted records do not show that Humira, a humanized monoclonal antibody which blocks TNF, has been tried and failed. As such, Stelara is not medically indicated for the 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 internal medicine with sub-specialty 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for caudal epidural injections with imaging guidance and under general anesthesia, every three months. Findings:  The physician reviewer found that submitted documentation supports the medical necessity of a portion of the requested services. Parr and colleagues concluded that there was good evidence for short-term and long-term relief of chronic pain secondary to disc herniation or radiculitis with local anesthetic and steroids. Further, the authors noted fair evidence for caudal epidural injections in managing chronic axial or discogenic pain, spinal stenosis, and post-surgery syndrome. Chou and colleagues reported that epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function, however, the benefits were small and not sustained, and there was no effect on long-term surgery risk. The authors further noted that limited evidence suggested no effectiveness for spinal stenosis. In this case, the patient has chronic low back and leg pain. He has back surgery syndrome and lumbar radiculopathy. He has developed scar tissue and chronic intractable nerve pain due to multiple spine surgeries and procedures. The patient has reported relief from caudal epidural steroid injections two to three times yearly, and he had requested sedation for the procedures due to severe procedural anxiety and pain related to advancing the epidural needle through scar tissue. While the current medical literature supports a caudal epidural steroid injection as an option for the management of radiculopathy and post-surgery syndrome, ongoing or continuing injection therapy is not medically indicated at this time. Responses to individual injections will determine the medical necessity of ongoing injections. In this clinical setting, the records do not reflect that general anesthesia is medically indicated over standard sedation. Current medical evidence supports conscious sedation in this patients case. Therefore, a caudal epidural injection is medically necessary for the treatment of this patient. The medical necessity of additional caudal epidural injections has not been demonstrated at this time. Additionally, general anesthesia is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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 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

A 46-year-old female enrollee has requested a mini gastric bypass for the treatment of morbid obesity.Findings:  Three physician reviewers found that National organizations such as the National Institutes of Health and the American Society of Bariatric Surgery have not recognized the mini gastric bypass procedure. There are only a few centers in the United States that are performing the procedure and the rates of bile reflux are a significant concern. The mini gastric bypass is not the standard of care and the procedure remains experimental. There is no clear indication that this patient could not be safely and effectively treated with standard bariatric procedures or that the mini gastric bypass offers a better surgical outcome.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for laboratory testing (CPT 81551). Findings:  The physician reviewer found that there is a lack of support for the services at issue in this patients case. The ConfirmMDx test is a multiplex polymerase chain reaction assay which measures DNA methylation of three biomarkers associated with prostate cancer: GSTP1, APC and RASSF1. The National Comprehensive Cancer Network (NCCN) guidelines do not consider the ConfirmMDx test standard of care in this setting. American Urological Association guidelines do not comment on the utility of the ConfirmMDx test in patients undergoing a prostate biopsy. At this time, there is limited data on clinical outcomes to support routine use of the ConfirmMDx test. Therefore, laboratory testing (CPT 81551) was not likely to have been superior over other methods of evaluating this patient. Final Result: Three physician reviewers found that the services at issue were not likely to be more beneficial for evaluation 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 urology 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

The patient is a 42-year-old male with significant brow ptosis and dermatochalasia of the upper eyelids. He has been evaluated by an ophthalmologist and noted to have visual field defects secondary to this aging change. The ophthalmologist has determined the patients condition would be best corrected by performing a brow lift. The Health Plan has authorized this procedure. A plastic surgeon has also evaluated the patient and has recommended a bilateral blepharoplasty in addition to the brow lift. The plastic surgeon makes no statement regarding the visual field defect. The Health Plan has denied coverage for the requested blepharoplasty on the basis it is cosmetic in nature and is not medically necessary for treatment of the patients condition.This patient has a documented visual field brow ptosis and upper lid excess and drooping. There is no evidence demonstrating what affect the brow lift will have on the patients upper lids. As such, the potential functional result of the brow lift is not known. It is possible that the brow lift alone will resolve the patients functional issues. If after the brow lift is performed a documented visual defect remains, the patients request for a blepharoplasty should be reconsidered. Based upon the information provided at this time, I have determined the requested procedure is 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 thoracic spine and of the lumbar spine.The submitted documentation does not support that the requested services are medically necessary. Joint guidelines from the American College of Physicians (ACP) and the American Pain Society explicitly recommend that clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. The joint guidelines state that clinicians should reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination.In this case, the patient has a history of degenerative disease affecting the neck and back. The submitted documentation reflects that the patient had MRI scans of his thoracic and lumbar spine as recently as 2017. This imaging demonstrated that the patient had some mild spinal stenosis of the lumbar spine, and no evidence of foraminal stenosis was noted. Records reflect that while the patient has subjective weakness, lack of mobility, and pain, no objective physical findings were noted that would indicate some deterioration of the back or legs. There are no objective findings on the physical examination or by history that would provide a clinical indication for the requested thoracic and lumbar MRI scans. Under these circumstances, the requested Magnetic Resonance Imaging (MRI) of the thoracic spine and of the lumbar spine  are not medically necessary for the 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 denials 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: Overturned

A 38-year-old male enrollee requested a cycle ergometer (motorized functional electrical stimulator cycle ergometer) for treatment of his spinal cord injury. Findings:  Two physician reviewers found that according to the current peer-reviewed literature, home-based functional electrical stimulation cycling is likely to be of greater benefit than other available standard therapy.  As paralyzed patients are at an increased risk for cardiovascular disease, exercise or therapy which is able to increase cardiovascular strength will help to decrease the risk for further adverse events.  Use of the requested device will help to increase cardiac stroke volume and cardiac output, and enhance overall neurologic and body composition health.  Functional electrical stimulation cycling has been shown to benefit patients with complete spinal cord injuries in terms of redeveloping and sustaining muscle mass and improving cardiac health.  Therefore, the requested cycle ergometer (motorized functional electrical stimulator cycle ergometer) is likely to be more efficacious than other modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for power wheelchair (group 3 heavy-duty, multiple option, sling/solid seat/back).  According to the Official Disability Guidelines (ODG), power mobility devices are recommended if the functional mobility deficit cannot be sufficiently resolved by the prescription of a cane or walker, the patient does not have sufficient upper extremity function to propel a manual wheelchair, or there is not an available caregiver willing and able to provide assistance with a manual wheelchair. Colleagues concluded that powered mobility device interventions mainly contribute to mobility-related participation by making participation easier for people with mobility restrictions and by increasing the frequency of aspects of participation (such as shopping for groceries and going for a walk/ride). The study conducted by colleagues further strengthens the current evidence that powered mobility devices increase mobility-related participation in daily life among certain subgroups of adults with mobility restrictions.Current evidence based medical guidelines and peer reviewed literature support this request based on his medical condition, limited mobility and strength, and to maximize his independent function. There is no evidence that his medical condition had improved over the past four years in order to support a different level of power mobility device. Therefore, the requested group 3 power wheelchair is medically necessary for treatment of the enrollees medical conditions. Final Result: The reviewer determined that the requested equipment 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: Overturned

Nature of Statutory Criteria/Case Summary: There is support in the medical literature for an eight week course of IOP services in this patients case. A study infers improved functionality and decreased mortality associated with individuals who complete IOP programming.  In this case, the patients alcohol use was complicated by co-occurring depression, anxiety and trauma related symptoms.  This is of particular relevance since it has been established in both clinical practice and the medical literature that anxiety ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes. Although the patient showed signs of steady improvement as evidenced by her two months of sobriety, medication adherence and ability to visit the patients workplace, she had not completed the time limited program. As the patient had not yet consolidated the issues that prompted the admission. The patient had significant psychiatric co-morbidity and unresolved issues generating distress. The patient lived alone. The patient was anxious and overwhelmed when visiting her workplace.  The patient was not sleeping well.  The patient was having urges to drink.  The patients mood was poor and sad, and the patient was frequently crying.  It appears that the patient was actively engaged in her treatment program, which included individual therapy, an array of groups and psychiatric services.  The patient was also mobilizing her social supports to buoy her recovery and autonomy, and developing an aftercare plan.  In sum, considering the relevant peer reviewed literature, current practice guidelines and the case in its entirety, service delivery at the IOP level of care was safe, appropriate and consistent with good medical practice. A two month treatment course aligns with community standards and would be reasonably expected to improve the patients condition, bolster relapse prevention efforts and prevent a more serious episode of illness.   Based on an admission date, the medical necessity for IOP services provided have been demonstrated as medically necessary, but not thereafter.  Given these findings, a portion of the services at issue was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue was 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: Overturned

The parent of a 10-month-old male enrollee has requested  for the DOC Band cranial molding helmet for treatment of the enrollees plagiocephaly.   Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning. Although rare, some cases are severe enough to require surgery for correction. Although positional head deformity is generally not a life-threatening condition, up to 10% of infants may have permanent deformity with subsequent complications (Biggs, et al). Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible. In 2003, the American Academy of Pediatrics (AAP) published prevention and management guidelines for positional skull deformities in infants. Therefore, the requested Doc Band was the most appropriate choice, and medically necessary and appropriate for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested occupational therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the submitted documentation supports the requested therapy for the treatment of this patient.  Feeding problems are common in childhood, and they can at times be severe enough to result in growth failure and susceptibility to chronic illness.  Up to 25% of all children have some form of feeding problem, and up to 80% of developmentally delayed children experience feeding difficulties.  The medical literature supports the utility and efficacy of a multidisciplinary approach in this clinical setting.  This patient has deficits in fine and gross motor skills, speech and language skills, hearing, and feeding skills.  Occupational therapy is an integral part of any feeding evaluation and intervention.  In addition, with its focus on developing motor planning skills, feeding skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in this patient.  All told, occupational therapy is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for urgent care services on the basis that the services at issue were emergent. Based upon the submitted documentation, the patient presented on two separate occasions to urgent care facilities. The first episode was for evaluation of a finger injury. The patient had suffered a distal phalanx fracture and was wearing a splint when he caught an object thrown at him. His finger `snapped back` and his finger splint was dislodged. The patient's digit was noted to be tender. An x-ray was ordered to assess for acute fracture and for mal-alignment of the previous fracture. Following this, a new finger splint was applied to stabilize the known fracture. A patient experiencing a new injury to a finger with a known fracture that results in displacement of a splint meets criteria for an emergency medical condition. As such, the services were necessary for treatment of an emergency medical condition. With regard to the second urgent care services received, the patient was evaluated for allergy symptoms. There was no sudden or acute deterioration. The patient was not short of breath. He had already been evaluated for his symptoms and was receiving medications. His symptoms were not unanticipated. Treatment of allergy symptoms does not meet criteria for an emergency medical condition. In conclusion, the services performed during the first episode were necessary for treatment of an emergency medical condition; however, the services received during the second episode were not necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services during the first episode, but not during the second episode. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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.