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

A 28-year-old female has requested referral to a pain management specialist for treatment of her back pain with radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, the requested referral for consultation with a pain management specialist is medically necessary to further evaluate and work-up the patient for her severe lumbar spine and possible radicular pain. The patient has a metabolic syndrome with morbid obesity and severe radicular pain. These conditions prevent her from exercise therapy and are also causing elevated cortisol and stress hormone response that may be exacerbating her weight problems. Referral to a pain specialist would allow for aggressive work-up with magnetic resonance imaging (MRI) or other radiographic modality to rule out disc herniation or nerve root compression. Further, the work-up would allow targeted therapy to alleviate her pain and may consist of physical modalities or interventional modalities depending on findings. She is a potential candidate for weight loss reduction surgery in the future, but would need to be able to exercise regularly and the referral to a pain specialist would be helpful in returning to an active lifestyle. For these reasons, the referral to a pain specialist to allow for the patient to be appropriately treated for her painful condition has been demonstrated to be medically necessary in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee requested authorization and coverage of total knee replacement surgery for the treatment of a knee injury.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placement of SpaceOAR Hydrogel. The records provided for review document that this patient presents with Gleason 4+3 prostate cancer. The patient was treated with radiation therapy with placement of SpaceOAR Hydrogel. As noted in the medical literature, SpaceOAR Hydrogel spacer placement can be utilized during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum. In a randomized phase 3 study in patients undergoing radiation for prostate cancer, the risk of adverse events grade 2 or higher at three-year follow-up was improved in hydrogel space group as compared to the control group. The patients treated with SpaceOAR Hydrogel also experienced a significant improvement in bowel quality of life. Results of a secondary analysis suggest that use of a SpaceOAR Hydrogel in this clinical setting can decrease sexual side effects and as well. The current National Comprehensive Cancer Network (NCCN) guidelines now endorse the use of a hydrogel space in patients undergoing radiotherapy for prostate cancer. Therefore, placement of SpaceOAR Hydrogel was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the placement of SpaceOAR Hydrogel was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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

The patient is a 14-year-old male who was placed in the High Top School following his stay in a residential facility in Hawaii. His placement in this program has the stated goals of improving his attention, improving his impulse control, taking his medications, helping parents set clear firm limits, improve his self-esteem and to develop positive social skills to help maintain lasting peer friendships.He started in the program in February 2006 with a projected graduation in February 2007. He currently is fully participating and taking his medications. At issue is whether these residential treatment services are medically necessary for treatment of the patients medical condition.The patient is an intelligent 14-year-old male with a history of ADHD, conduct disorder, depression and anxiety. He has had difficulty with peers and was sent to a residential treatment facility in Hawaii prior to his placement at the High Top Ranch School by his parents. He started at the facility in February 2006 with the plan to attend school, and to participate in the programs that they offer.Although the program does offer access to psychiatry and to health care, it is on a limited basis. A review of the submitted records reveals that the psychiatrist comes to the school approximately twice per month. Each student is assigned a counselor who sees the students individually. The counselor for this student is a LCSW. The students also participate in groups with other students. The record reveals that the medications prescribed for the student are continued. The notes from the consulting psychiatrist document changes in the dosages of his medications. The primary function of the residential program is a therapeutic school. The services being provided do not appear to be consistent with a medically supervised residential program in accordance with psychiatric community standards. As such, the medical necessity of these services has not been established. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multiple seat function kit (E2311) for treatment of the enrollees Duchenne muscular dystrophy. Findings:  The physician reviewer found that the benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. In this case, the patient has personal mobility and self-care deficits which the requested equipment will lessen. In addition, the requested device increases flexibility of positioning to reduce the risk of skin breakdown and makes him more independent. The requested multiple seat function kit will likely improve his ability to transfer, reposition to relieve pressure, and participate in activities of daily living. As such, the requested multiple seat function kit (E2311) has been established as medically necessary for treatment of the patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

The parent of a three-year-old male enrollee has requested speech therapy for the treatment of the enrollees articulation and language deficit secondary to verbal apraxia. Findings:  The physician reviewer found that verbal apraxia is a congenital disorder due to failure of speech development in the Broccas area of the temporal lobe of the dominant [usually the left] cerebral hemisphere of the brain. It is a treatable disorder, with anticipated improvement in articulation and expressive speech. This patients speech improved from no linguistic skills to a vocabulary of 40-50 words and 2 word phases during 5 months of speech therapy. He has progressed from language of a less than one-year-old child to the level of a two-year-old child following 27 speech therapy sessions. Thus, as a congenital disorder that is treatable, it is designated as a treatment of medical necessity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stretta procedure for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that there is inadequate clinical data from evidence based guidelines and published well-constructed randomized clinical studies to conclude that Stretta results in long-term improved clinical outcomes for GERD. A systematic review to evaluate evidence on the efficacy of Stretta for the management of gastroesophageal reflux did not show any benefit of Stretta over sham therapy. Specifically, data on the mean percentage of time that pH was less than 4 over 24 hours showed no significant benefit of Stretta over sham therapy. In addition to lack of efficacy, adverse events reported to the U.S. Food and Drug Administration (FDA) include pneumonia, gastroparesis, esophageal perforation, and cardiac arrest. Support for the Stretta procedure among national medical societies varies and the most recent American College of Gastroenterology guidelines on GERD reported that current endoscopic therapycannot be recommended as an alternative to medical or traditional surgical therapy. For these reasons, Stretta procedure is not supported as medically necessary for the treatment of this patients GERD. Final Result: The reviewer determined that the requested service 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 gastroenterology 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 60-year-old female enrollee has requested office visits, physical medicine rehab and injection of tendon and coverage for future services for treatment of her pancreatitis and lumbar spondylolisthesis. Findings:  Three physician reviewers found that the medical records provided are brief and are accompanied by a typed document of an unknown source entitled Auriculoneural Therapy which describes this therapy as a technique involving the detection of tender spots or points with reduced electrical resistance on the ear which coincides with painful and/or symptomatic areas of the body. In review of this case, there is a lack of detailed medical records from the attending physician demonstrating the necessity of the services at issue.  The providers records do not include a history of physical examination, impression and discussion of a treatment plan and a possible alternative treatment plan. There is limited mention of prior treatments that have been provided.Although multiple articles have been submitted which report some benefit with auriculotherapy, these studies do not demonstrate that this therapy is more effective than alternative conventional treatment for this patients condition. Anecdotal reports regarding the benefits of this treatment are not valid as a means of determining the efficacy of treatment.  In order to determine the efficacy of such treatment, it should be compared to alternative treatments. This is particularly important in a situation such as spondylolisthesis, where there are numerous generally accepted invasive and noninvasive treatment options. Therefore, the medical records and the medical literature do not support that the services at issue were and/or are likely to be more efficacious than treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male has requested speech therapy and occupational therapy for treatment of his autism. Findings:  The physician reviewer found that the use of speech therapy for patients with autism, the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.).Regarding the effectiveness of occupational therapy for children with autism, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of occupational therapy in the autistic childhood population. A study by Pfeiffer, et al. found that occupational therapy utilizing sensory integration techniques is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee requested authorization and coverage of a referral to an out-ofnetwork provider for the treatment of rectal cancer.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female requested coverage for inpatient mental health services level of care provided from a specific date and forward.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings are thought to offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. In this particular case, acute hospitalization was indicated and consistent with the American Psychiatric Association (APA) treatment guidelines. Discharge on the date in question would have more than likely burdened the patient with undue morbidity and an elevated risk for readmission. The patient was described as feeling worthless with a poor body image by staff, while the physician reported active suicidality with hopelessnes. Since that time, the patient has remained symptomatic with prominent emotionality, marginal attention to performing activities of daily living, and with a poor body image and acute suicidal ideation. Although the patient is beginning to explore the core conflictual issues in therapy, which represents a critically meaningful pursuit, this endeavor is ideally suited for a less restrictive setting. As such, the documentation provided supports placement at the acute setting through three days, after which time the patient was a candidate for transitioning to a lower level of care such as a partial hospitalization program.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this case concerns the medical necessity of speech therapy services twice a week for the treatment of this 2-year-old male with developmental delay with respect to speech and language. Given his delay and based on overall evaluation of the relevant peer reviewed medical literature, including positive and negative analyses, these services are clinically indicated. Key to this patients case is that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with speech delay. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to speech delay.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for a wearable cardioverter defibrillator LifeVest provided by Zoll. Based on the records provided for review, this patient has severe non-ischemic cardiomyopathy with class II congestive heart failure that persisted despite goal-directed medical therapy. The current guidelines state that a wearable cardioverter defibrillator may be indicated for patients with a left ventricle ejection fraction (LVEF) under 35% when an implantable cardioverter defibrillator (ICD) cannot be placed, needed to be significantly delayed due to infection or other medical condition, or required explantation. This patient met the criteria for an implantable defibrillator. There is no documentation of a need to delay ICD placement or that the patient had a contraindication to ICD placement. In this clinical setting, the appropriate course of action would be for the patient to undergo ICD placement in lieu of using an external wearable cardioverter defibrillator. Given these findings, the wearable cardioverter defibrillator LifeVest provided by Zoll was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the device at issue was 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 subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for transanal hemorrhoidal dearterialization (THD) (CPT code 0249T). The enrollee had bleeding hemorrhoids and a family history of colorectal cancer.  Enrollee underwent a colonoscopy, which revealed internal hemorrhoids and diverticulosis. His hemorrhoids caused discomfort and rectal bleeding and the physician treated them with sclerotherapy, but his symptoms returned. He has also tried medications and a high fiber diet.  His colorectal surgeon states the enrollee had grade III  IV internal hemorrhoids that had failed conservative management.  He underwent transanal hemorrhoidal dearterialization (THD).  His surgeon states that the procedure done was ambulatory and the enrollee had immediate and effective symptom control.  At a follow-up visit. the enrollee reported no pain or bleeding since the procedure. Transanal Hemorrhoidal Dearterialization (THD) has been studied with randomized controlled trials and long-term follow-up supports the benefit in appropriately selected enrollees, such as this one. Findings: the physician reviewer found that the medical literature assessed the current evidence regarding THD to evaluate the safety and efficacy of the technique, define its indications, and identify its possible advantages and limitations.  The results were that THD is a viable treatment option for second-degree and third-degree hemorrhoids. Studies using Doppler-guided hemorrhoidal ligation demonstrated favorable results. A clinical trial found there were no major complications in the course of 50 patient treatments. Patients pain scores improved compared to traditional hemorrhoidectomy, and similar long-term cure rates were demonstrated when compared to excisional hemorrhoidectomy.  Based on the current body of peer reviewed literature regarding THD, this procedure has withstood adequate peer reviewed scrutiny, has been evaluated with prospective randomized controlled analysis, and is likely to be more beneficial for appropriately selected patients as in this case.Final Result: Two of the three reviewers determined the requested service is likely to be more beneficial than any other available standard service for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in surgery and one reviewer is board certified in colon and rectal surgery. All 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan with Gallium 68 PSMA-11. Findings:  The physician reviewer found that Gallium-68 PSMA-11 PET has been increasingly studied for the evaluation of patients with biochemical recurrence after primary treatment of prostate cancer. However, the test is not considered a generally accepted standard of care for routine use in all patients with biochemical recurrence after prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines cautioned that Gallium-68 PSMA PET imaging has been associated with high rates of false-positive results. The American Urological Association (AUA) guidelines reported that there are limited data available to support an indication for PSMA in patients with possible metastases. All told, the requested PSMA PET scan with Gallium 68 PSMA-11 is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested PSMA PET scan with Gallium 68 PSMA-11 is not likely to be more beneficial for evaluation 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 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.