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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 15 hours per week of direct applied behavior analysis (ABA) services. To determine the medical necessity of ABA, A study provide guidelines. According to the authors, the definition entails: healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the presenting information, this patient does not meet criteria (c) and (e). The provider has recommended a lesser intensity of service. However, in the attached authorization addendum, there is insufficient information beyond a reported average of interfering behavior including aggression 1.75, property destruction 1, and work refusal 1.3 times per session. The sessions are over two hours, which suggests that the patient is engaging in problem behaviors less than twice per hour. In addition, there is no other description of the patients current level of functioning or data to determine his progress. Given this dearth of information, there is not enough evidence that the patient requires any level of service delivery. Moreover, the provider recommended a fading of services to transition to parent directed services. This indicates that therapist directed sessions would be a more restrictive form of service delivery than appropriate. All told, the requested 15 hours per week of direct ABA services are not medically necessary for 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 a licensed B.C.B.A board certified in psychology 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

A 19-year-old male enrollee requested authorization and coverage of an insulin pump for the treatment of type I diabetes mellitus.  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 upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Depo-Testosterone.The submitted documentation supports that the requested medication is medically necessary. Low testosterone can lead to such complications as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, low bone mass, depressed mood and fatigue. For these reasons, many physicians treat patients with hypogonadism when their testosterone level is less than 350 ng/dl. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. In this case, the patient has been taking growth hormone under the care of an endocrinologist, and lab testing has shown that he has total testosterone that is at the low end of the general target level, and free testosterone that is below the reference range for adult males. Under these circumstances, the requested Depo-Testosterone is medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of 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 endocrinology, diabetes and metabolism, 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 the resumption of care at a skilled nursing facility (SNF) with physical therapy for treatment of the enrollee, who has a history of chronic hypercapnic respiratory failure. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested services in this clinical setting. In this case, the patients medical condition appears stable. There are no complex wound care needs. She does not require medical oversight of her condition at a hospital level of care. She had shown some progress but the gains had been very minimal. There were no medication concerns and discharge home was being recommended. Her burden of care was unchanged since the start of care. The patient made no functional improvement as of the date in question and there was no reasonable expectation of achieving gains that would impact the burden of care at discharge. The patients care can be provided at a lower level of care including through custodial care. 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 physical medicine and rehabilitation 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

A 51-year-old female has requested coverage for a bone density scan/dual energy x-ray absorptiometry (DEXA) scan for evaluation of her bone pain.  Findings:  The physician reviewer found that the record provided for review does not establish that this patient is at risk for osteoporosis. Pain alone is not an indication of osteoporosis or bone loss. The patient is 51-years-old and there is no documentation that she is in menopause or has any other form of estrogen deficiency. Her comprehensive metabolic panel, including calcium, kidney function, and complete blood count (CBC) are all normal. The patient has diabetes but this is reportedly well controlled. In addition, the patient has no history of fractures or history of glucocorticoid use. Entering this patients data into the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX), the 10-year risk for fracture in this patient is not elevated because she does not have any documented risk factors that increase this score. Thus, based on the information available, the patient does not meet the criteria established by the National Osteoporosis Foundation (NOF) and the International Society for Clinical Densitometry (ISCD) for a bone density study.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the SpaceOAR system (insertion of a perirectal hydrogel spacer). The enrollee has prostate cancer. His treatment plan includes radiation therapy. His radiation oncologist has recommended the SpaceOAR System, which involves the insertion of a perirectal hydrogel spacer prior to initiation of the radiation therapy to help reduce damage to the rectum during treatment. His physician indicates the SpaceOAR allows an increased dosage to the prostate gland while decreasing the dosage to the organs at risk. The physician reports the SpaceOAR System will enhance radiation treatment while preserving healthy tissue to help ensure that rectal, urinary, and sexual quality of life may be maintained. Literature shows the spacer materials have an excellent safety profile and can be implanted in a well-tolerated procedure. The separation reduces the volume of rectal tissue receiving high doses of radiation, and can reduce the maximum dose delivered to the rectum. This enrollee would be an ideal candidate for this procedure, because he has low-risk prostate cancer and his cancer is located in the apex, which is relatively closer to the anterior rectal wall.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested authorization and coverage for a gastrointestinal tract capsule endoscopy.   The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of gastrointestinal bleeding.  Findings:  Three physician reviewers found that the patient has required blood transfusions because of recurrent gastrointestinal hemorrhage. Colonoscopy and upper gastrointestinal endoscopy have been non-diagnostic.  A bleeding jejunal arteriovenous malformation was identified during upper endoscopy and was ablated.  No other candidate bleeding lesion has been found.  The gastrointestinal hemorrhage has been sufficiently severe to result in cardiac complications for which she may require systemic anticoagulation with warfarin.  Wireless capsule endoscopy has been requested to further evaluate the small intestine for additional potential sources of gastrointestinal hemorrhage. The Health Plan has denied coverage for gastrointestinal tract capsule endoscopy and reported that the requested services are investigational for the evaluation of this patient.  This patient has gastrointestinal bleeding of obscure origin that has been recurrent and has required transfusions. Upper endoscopy identified a bleeding jejunal arteriovenous malformation that was ablated, and colonoscopy was non-diagnostic.  Search for an additional small bowel source of recurrent gastrointestinal hemorrhage, in light of the potential need for systemic anticoagulation for cardiac reasons, has been appropriately considered.  The diagnostic test of choice to evaluate the small intestinal mucosa is wireless capsule endoscopy. The Health Plan has noted that small bowel radiography should be done prior to granting approval for the gastrointestinal tract capsule endoscopy.   However, small bowel radiography cannot identify a mucosal lesion such as a bleeding arteriovenous malformation or sometimes shallow ulcerations. Small bowel radiography can identify small bowel tumors and large polyps.  However, the likelihood that a small bowel tumor or large small bowel polyp is the reason for the patient's recurrent gastrointestinal hemorrhage is much less than the likelihood of an arteriovenous malformation. All told, the requested gastrointestinal tract capsule endoscopy is likely to be more efficacious than other available tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services, including detoxification for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. This particular patient had significant comorbidity.  She was diagnosed with bipolar disorder and multiple substance use disorders. Based on the documentation provided, the patient was not responding well to psychiatric services in the outpatient setting.  Further, the patient had treatment ambivalence while her motivation for recovery was poorly consolidated. Indeed, she walked away from treatment days before the disputed admission and skipped many treatment sessions early in the treatment course.  Finally, the strained parent-child dynamics posed a significant barrier to safe housing options and community-based service delivery.  The services and setting were safe, appropriate and consistent with good practice. Additionally, the services provided were reasonably expected to improve her condition and prevent a more serious episode of illness, while the duration of care was consistent with community standards. In sum, considering the clinical presentation and the relevant peer-reviewed literature, substance abuse residential treatment center services, including detoxification, were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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

A 52-year-old female enrollee has requested acute inpatient hospitalization admission for treatment of her behavioral health condition. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The patient was admitted for acute inpatient hospitalization treatment secondary to suicidal thinking. Although she presented to the emergency room complaining of worsening depression with suicidal thinking, and a 5150 voluntary hold was placed, there was no evidence that she represented an imminent serious harm to herself. She did not demonstrate a plan or intent to harm herself with an available means, there was no recent attempt to harm herself and there was no continued imminent risk. She did not demonstrate poor impulse control. She was able to care for herself and was not showing disorganized or bizarre behavior. She did not demonstrate threat of harm to others. She was not gravely disabled. She did not show psychotic ideation. Her medication management could have been safely and easily managed at a lower level of care. Thus, the patient could safely have been treated at a lower level of care during the services in dispute. In sum, the patient did not meet the medical necessity criteria for acute inpatient hospitalization admission.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested the Medtronic continuous glucose monitoring system (CGMS) for the treatment of his type I diabetes mellitus. Findings:  The physician reviewer found that primary type 1 diabetes mellitus is an autoimmune disease and the patient has secondary diabetes due to pancreatectomy without the added comorbidity of autoimmunity. This may in fact significantly decrease his likelihood of developing the micro and macro-vascular complications found in true diabetes mellitus type 1. Additionally, a glucometer measures blood glucose and gives an instantaneous measurement of blood glucose values. The CGMS measures interstitial glucose levels and there can be a delay of up to 20 minutes before increases or decreases in blood glucose levels are reflected in interstitial fluid measurements. The CGMS will not prevent hypoglycemic events or provide an instantaneous warning in the event of a precipitous drop in blood glucose levels. The CGMS is not essential for accurate blood glucose monitoring.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested bilateral breast MRI studies for an evaluation her breasts, due to the fact that she has a previous history of breast cancer. Findings:  Three physician reviewers found that this patient does not fall into the group of patients requiring breast MRI exams for routine surveillance. First, the breast tissue has been described on mammographic reports as heterogeneously dense. This type of parenchyma permits a useful evaluation by radiologists for initial or recurrent tumor, as opposed to the extremely dense parenchyma. In the latter case, mammography is of quite limited value. In patients with heterogeneously dense tissue, mammography is quite useful.  If there is any clinical or mammographic change suspicious of tumor recurrence, a follow-up ultrasound and possibly an MRI would be the procedure of choice. This is not the case at this point.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female who has a history of cervical and lumbar discogenic disc disease. She has demonstrated continued low back pain and radiculopathy despite medical therapy. It has been recommended she undergo a series of lumbar epidural steroid injections. The patient has requested authorization and coverage for a referral to an anesthesiologist for epidural steroid injections. The Health Plan has denied this request indicating that the requested referral is not medically necessary for treatment of the patients medical condition.The patient has been referred to a neurosurgeon for epidural steroid injections. There is no documentation demonstrating the medical necessity for the epidurals to be administered by an anesthesiologist. Epidural steroid injections can be safely and appropriately administered by a neurosurgeon. The submitted information indicates the neurosurgeon has performed the procedure in the past. The request for the epidural injections to be performed by an anesthesiologist is not medically warranted. Therefore, I have determined the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for lumbar fusion surgery services. Researchers found that in patients with degenerative grade 1 spondylolisthesis, fusion significantly improves quality of life versus simple decompression alone. The records provided for review document a longstanding history of chronic back pain that has persisted despite at least six months of conservative care. Treatment modalities have included physical and aquatic therapies, medications, yoga, and chiropractic care. The patient has been treated by pain management for over two years. Steroid injections were initially beneficial but were less effective just prior to surgery. In addition, there is report of imaging studies demonstrating a structural and progressive source for the patients symptoms. There are magnetic resonance imaging (MRI) studies and x-rays that show evidence of a progressive isthmic spondylolisthesis with severe left-sided foraminal stenosis at L4-5 or L5-6, and meaningful and substantial instability. The flexion and extension films demonstrated 5 mm or greater of moving listhesis at the affected level, which supports instability. Moreover, there is greater listhesis on upright x-rays versus his MRI scan. Finally, the process has been rapidly progressive, with his first provided MRI documentation reporting a mild anterolisthesis in 2018, to standing films that note a grade 2 spondylolisthesis just prior to surgical intervention in 2020. A recent review of guidelines also supports the use of fusion procedures in appropriately selected patients who have failed conservative therapies. In this case, the current patients condition included a higher grade isthmic spondylolisthesis that was unstable. Spinal fusion, in conjunction with decompression was the treatment of choice for the management of this patients higher grade isthmic unstable spondylolistheses. For these reasons, the lumbar fusion surgery services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.