Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Oncotype Dx Prostate Assay for evaluation of the enrollees prostate cancer. Findings:  The physician reviewer found that The physician reviewer found there currently are three major approaches to the management of localized prostate cancer. These include surgical prostatectomy, various forms of radiation therapy, and active surveillance with no specific treatment. Recommendations are made as to these options based on risk stratification, which estimates the risk for the future development of progressive cancer. The individuals prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen, and pathologic details, including Gleason grade and the number of biopsy cores that are positive.  Thus, patients can then be placed into one of four general categories: very low risk, low risk, intermediate risk, and high risk. By such categorization, this patient would be placed in the low to intermediate risk category, for whom active surveillance is a recommended option. A further evaluation of prognostication is the use of gene panels of the cancer cells, one of which is Oncotype Dx Prostate Assay. This is a 17-gene panel that may assist in predicting recurrence risk after treatment for prostate cancer. However, at this time, it has not been clinically validated in this setting as beneficial for decision making about treatment or surveillance. Therefore, the superior effectiveness of Oncotype Dx Prostate Assay has not been established. Final Result: Two of three reviewers determined 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 43-year-old female has requested coverage for a CT scan and an EMG nerve conduction study for evaluation of her tail bone and lower back pain.  Findings:  The physician reviewer found that the available peer-reviewed medical literature indicates that there is no need for a CT scan when an MRI is feasible to make the diagnosis. In the case of this patient, an MRI was performed and demonstrated mild grade 1 spondylolisthesis and facet arthropathy. Thus, a CT scan is not likely to be of clinical value in this setting. Further, this patients clinical picture is not consistent with a far lateral disc herniation; nor does the evidence suggest that a disc herniation is the causative agent for her low back and tail bone pain. Therefore, there is no medical indication that an EMG nerve conduction study is necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested 12 additional physical therapy sessions for treatment of her status post partial right knee replacement.  Findings:  The physician reviewer found that the patient had not achieved functional flexion in her right knee and required the skills of a therapist to continue manual treatment. Following a knee replacement, one of the most important elements of physical therapy is to achieve good flexion. This is necessary for normal ambulation, sitting and climbing. This patient progressed with her active flexion, albeit slowly, but needed continued skilled PT to maximize flexion. Medicare guidelines consider PT necessary for treatment of a malfunctioning body part when progress is expected in a reasonable period. A systematic review published in 2007 concluded that there was a small but significant difference in range of motion with PT after knee arthroplasty. Standards of practice generally include providing skilled PT following knee replacement until the patient achieves maximal range of motion. This patient had not reached a plateau and would not have been able to achieve continued improvement without additional skilled PT. Thus, the disputed PT services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for two hours per week for treatment of the enrollees expressive language disorder and lack of coordination of the oral cavity.  Findings:  The physician reviewer found that based on review of the available records, this two-year-old male patient presents with severe developmental expressive speech aphasia. This is probably on a congenital basis, with the history of an older brother who is dyslexic. The patient is noted to be intellectually normal. He likes to attend his pre-school program for four hours per day, but despite this socialization with his peers, he has only slowly gained in his expressive ability. This suggests that this delay is not due to a physiological delay, but due to a congenital aphasia. His primary care provider is thus in accordance with the medical community, whose customary and usual practice would be to refer this patient for speech therapy. There is a strong peer reviewed medical literature supporting speech therapy in this child. Law and colleagues reported that children with speech delay can be readily and successfully treated. Goorhuis-Brouwer and Kniff evaluated the effect of speech therapy on language comprehension, language production and non-verbal functioning in two groups of children with developmental language disorders. The authors concluded that, verbal and non-verbal development can improve in young children with developmental language delay. Buschmann and colleagues concluded that a general wait and see approach is not justified in young patients with speech and language delay. In addition, the authors reported that two-year-olds, who tested below the 10th percentile (such as this patient), were successfully treated and subsequently benefitted from speech therapy. For these reasons, speech therapy is medically indicated for this patient at the requested frequency of twice per week for one hour sessions.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested authorization and coverage for individual therapy for treatment of the enrollees depression and anxiety.   Findings:  The physician reviewer found that based on review of the available records, this patient was a complicated individual with medical and mental health problems. Her personality disorder predicts trouble with mood and somatic symptoms more than her diagnoses would predict. As such, outpatient mental health services continue to be medically necessary to manage all of her symptoms and offer support during her follow-up for psychosocial issues. The fact that she is not enrolled in group therapy is not an adequate justification to deny her individual therapy. The records do reflect active goal setting and objectives as well as appropriate monitoring of symptoms. Consistent with these findings, the requested individual therapy has been demonstrated to be medically necessary for treatment of this patients medical condition at the frequency of every other week.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a three month refill of Effexor 150mg, a three month refill of Seroquel 200mg, individual psychotherapy every two weeks, and monthly visits with a psychiatrist. The enrollee has chronic recurrent depression and anxiety, exacerbated by recent stressors. Her symptoms were relatively well-managed until she had a panic attack in March. Subsequently, her medications were changed and her mood worsened causing her to have panic attacks every week. She started having suicidal ideations since she was getting two weeks supplies of medication, and wanted more.  She was scheduled for a psychiatry follow-up for a second opinion, and larger supplies of Effexor XR and Seroquel but was unable to follow through with the appointment. She had not taken Seroquel or Effexor XR for three days and felt withdrawal symptoms, as a result. Although the enrollee continued to display significant depression and multiple neuro-vegetative signs, she did not want to restart an intensive outpatient program. She indicated she was willing to restart the medications and requested more frequent appointments. Review of the record indicates the enrollees overall functional ability was mildly to moderately impaired. Her physician indicated mild psychomotor agitation, but no abnormal movements or tardive dyskinesia symptoms.  The enrollees speech was normal and coherent, and her thought process was logical and goal-directed.  The enrollee vocalized no suicidal ideation, plan or intent and her insight/judgment was average.  Her symptoms were exacerbated by recent stressors, and she was in medication withdrawal. She was not a danger to herself.  Medical records indicate Seroquel was prescribed for the enrollee for major depressive disorder.  However, the request for three refills is excessive because the enrollee is evaluated monthly by her psychiatrist. The records indicate the enrollee was scheduled for individual psychotherapy every two weeks, which is medically necessary for this enrollee.  The medical literature also indicates the psychiatrist should determine the least restrictive setting for treatment that will be most likely to address the enrollees safety and promote improvement in the enrollees condition, including the frequency of visits.  The records indicate a request for monthly visits with a psychiatrist, which is medically necessary for this enrollee.  Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly allergy/immunotherapy injections (CPT codes 95117 and 95144). The submitted documentation fails to demonstrate the medical necessity of the requested services. Allergy shots are indicated for persistent symptoms on a seasonal and/or perennial basis for patients with an inadequate or partial response to environmental control and medications. The medical evidence supports skin testing and allergy shots as an effective treatment for allergic rhinitis, asthma and atopic dermatitis. As noted by researchers, the maintenance phase begins when the effective therapeutic dose is reached. Once the maintenance dose is reached, the intervals between allergy injections are increased. The dose generally is the same with each injection, although modifications can be made based on several variables. The researchers noted the intervals between maintenance immunotherapy injections generally range from four to eight weeks for venom and every two to four weeks for inhalant allergens but can be advanced as tolerated if clinical efficacy is maintained. In this case, the medical records indicate that the patient is on maintenance therapy. The maintenance therapy is for inhalant allergies and would typically be every four weeks, and up to every two weeks, if needed. The medical records fail to demonstrate the need for weekly injections during the maintenance phase. Therefore, weekly allergy/immunotherapy injections (CPT codes 95117 and 95144) 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 allergy and immunology 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:  An enrollee has requested authorization and coverage for Cuvitru subcutaneous immune globulin infusion.Research indicates, Intravenous immunoglobulin (IVIG) therapy is U.S. Food and Drug Administration approved for the immune-mediated peripheral nerve disorders Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. The authors also state, Small fiber polyneuropathy may manifest clinically as postural tachycardia syndrome, orthostatic intolerance, orthostatic hypotension, inappropriate sinus tachycardia. Management for autoimmune polyneuropathy includes treating the underlying disease as well as symptomatic relief. Currently, there are multiple reports of treatment success with the use of IVIG for autoimmune small fiber peripheral neuropathy, while randomized controlled trials are underway investigating the efficacy of IVIG. In this case, patient presents with dysautonomia caused by peripheral autonomic dysfunction due to an immune-mediated small fiber polyneuropathy. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Cuvitru subcutaneous immune globulin infusion is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 allergy and immunology 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

This patient is a 35-year-old male with back pain, which radiates to his legs. The patient indicates he has received chiropractic treatment in the past. X-rays of the lumbar and thoracic spine from August and December 2003 do not reveal significant bone disease. The findings show possible spina bifida occulta at S1 and loss of lordosis. Physician office visit notes from April 2005 mention coccygeal pain radiating to the patients legs for two years, which was recently aggravated. The patient is taking NSAIDs and performing home exercises. He has requested authorization and coverage for physical therapy. The Health Plan has denied this request citing a lack of medical necessity for the requested therapy.Upon review of the submitted records, it appears this patient has musculoskeletal back pain. As such, the patient may benefit from a physical therapy evaluation and instruction in pertinent exercises involving body mechanics and posture. Therefore, four to six physical therapy visits are medically indicated in order to attempt to improve this patients functional ability and decrease his discomfort. Accordingly, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for weekly speech therapy and feeding therapy services co-administered in one session. Based on the available documentation, this patients condition warrants the requested speech and feeding therapy to improve the dysphagia, strengthen lingual movements, and improve jaw stabilization. Speech therapy will address the patients articulation, expression, and communication skills. He previously received treatment with slow progress. Since transitioning to his current provider, a speech and feeding specialist with expertise in treating Down syndrome, he has made progress. He has developed a bond with his current provider, which is also bilingual, which has facilitated treatment. Moreover, the combined speech and feeding therapy has been effective for this patients progress. Therefore, the weekly speech therapy and feeding therapy services co-administered in one session were and are medically necessary for treatment 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 physical medicine and rehabilitation with expertise in pediatric rehabilitation 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

A 24-year-old female enrollee has requested for inpatient mental health hospitalization services for treatment of her mental health conditions. Findings:  The physician reviewer found that Depressed patients with suicidal ideation and plan, who also have significant medical comorbidities, and limited family and social support, are at elevated risk for suicide.  In such cases, psychiatric hospitalization is recommended by the American Psychiatric Association (APA). The APA Clinical Practice Guideline states: In determining a patient's initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. The interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population. In this particular case, the combination of depression, bulimia, intimate relationship stressors and personality organization was fueling a robust symptom complex and the patient was clearly demonstrating psychiatric distress while in the hospital. There was no evidence of a repeat risk assessment or preparation of an outpatient safety plan which is a tool that can mobilize the chronically suicidal population and help facilitate discharge. Further, the patient continued to endorse struggles with food and her appearance.  However, based on the documentation provided, these sub-acute issues would be appropriate for a less intensive setting.  All told, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee requested weekly podiatry office visits for medical treatment of the enrollees foot ulcer. Findings:  The physician reviewer found that based on the available information, weekly podiatry office visits are not medically necessary. The records do not indicate the problem with the large toe is caused by a chronic disease or that his condition has impaired the patients ability to walk. A disorder of the foot would include a situation complicated by diabetes and review of the documentation does not provide support the diagnosis of a complicated disease causing the ulceration. In addition, there is no evidence the patient is at risk for amputation. Without these criteria being met, the patients clinical situation does not warrant weekly office visits. For these reasons weekly podiatry office visits are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested authorization and coverage for 12 hours per week of direct one-to-one applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that the sources reported that ABA is the most evidence based approach to address deficits displayed by patients with autism. Other sources indicate that service intensity should be dictated by the patients need and results of the assessment. This patient displays deficits in social communication that places him several months behind his peers. Thus, the requested 12 hours per week of direct one-to-one ABA therapy is supported as medically necessary for treatment of this patients medical condition. 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 a board certified psychologist and is a board certified behavioral analyst 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 patient has a body mass index greater than 40 with obesity related comorbidities. She began a program to lose weight preoperatively and lost 10 pounds. She then took a break from the program for personal reasons and regained to 255 pounds. The Health Plan indicates the patient must meet the preoperative weight loss goal of 220 pounds prior to weight loss surgery. The Health Plans denial should be overturned. There is not significant additional risk to the patient if she weighs 255 pounds versus 220 pounds when gastric bypass surgery is performed. There is no specific medical reason to require the patient to undergo preoperative weight loss from a technical or evidence-based point of view. Therefore, I have determined that it is not medically necessary for the patient to decrease her weight to the recommended preoperative weight prior to gastric bypass surgery. The Health Plans denial should be overturned.