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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services, partial hospitalization program (PHP) services and intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that According to the documentation submitted for review, the patient showed post-acute withdrawal symptoms which were at best moderate.  The patient was medically stable.  There were no emotional or behavioral factors present, however the patient had cognitive impairment manifested by short term memory difficulties. The patient was uncertain of the date and was unable to perform serial additions. The patients past history suggests a high probability of impulsivity if discharged.  The patient was not manic or psychotic, nor a danger to self or others. The patient has been in multiple detoxes and other treatments, as well as 12 steps with a sponsor, still showing an inability to remain sober beyond 14 months, and relapsing while on Suboxone maintenance. The patient was compliant and engaged in treatment but showed no indication of having coping skills. Thus,  the patient was able to recognize triggers towards relapse, and could have been stepped down to an ambulatory level of care, while remaining on medication assisted treatment (Suboxone), which is typically done on an outpatient basis. The patients appetite, sleep, and post-acute withdrawal symptoms improved. The patients vital signs were stable. The patient became internally motivated and was highly engaged. There were no medication changes other than adding Paxil and naloxone spray. The patient could have been treated at IOP level of care, then moved to an outpatient level of care. Both IOP and outpatient levels of care could have been supplemented with community supports of 12 step programs, counselors, sponsors, outpatient therapists, and reaching out to sober support systems. For the reasons provided, the residential treatment center services provided were medically necessary for treatment of the 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 with sub-specialty certification in addiction 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: Upheld

The parent of a 15-year-old female enrollee has requested electroconvulsive therapy (ECT) for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that electroconvulsive therapy (ECT) is not an appropriate or indicated treatment for this patients mental illness. According to guidelines developed by the American Academy of Child and Adolescent Psychiatry, before an adolescent is considered for ECT, the patient must have a diagnosis of severe, persistent major depression or mania with or without psychotic features; schizoaffective disorder; or schizophrenia (Ghaziuddin, et al.). This criterion is not met. This patient has poor coping skills, suicidal behaviors and acting out behaviors that indicate Axis II pathology, most likely borderline traits or personality disorder (Lewis). Review of the scientific literature does not reveal support for the use of ECT for treatment of this patients mixed diagnostic compilation. She does not have a clear history of any sustained psychosis. The efficacy of ECT in this setting is not evidence based and the therapy poses the risk of side effects. This patient has not undergone adequate medication or therapeutic treatment, and does not have a diagnosis that qualifies her for ECT treatment consideration.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy, physical therapy and occupational therapy services for treatment of the enrollees developmental delay. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers. (Shevell, et al.) The main goal of treatment is to enhance an individuals level of functioning. This patient has expressive and receptive speech of approximately 40% per the Rossetti Infant-Toddler Scale and Developmental Assessment of Young Children with mild cognitive delays. Speech therapy is medically necessary with any delay greater than 25%. Extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, this patient has delays noted in gross motor skills and fine motor skills. Appropriate therapies in this setting include physical and occupational therapy, which are medically necessary and promote adaptive skill development and independence. (Wolraich, et al.)
Appeal type: Medical Necessity
Decision: Upheld

: An enrollee has requested authorization and coverage for a C-Stim Unit neuromuscular stimulator (CPT code E0745).Kroeling and colleagues conducted a systematic review of randomized controlled trials (RCTs) and concluded that electrical muscle stimulation did not reduce pain or disability for patient with neck pain. They indicated that future trials on these interventions should have larger patient samples, include more precise standardization, and detail treatment characteristics. Alrwaily and colleagues conducted a randomized controlled trial to investigate the clinical benefit of using neuromuscular electrical stimulation as a supplement to stabilization exercises in patients with chronic low back pain. They concluded that supplementing stabilization exercises with neuromuscular electrical stimulation did not offer any additional clinical benefit for the trials chronic low back pain patients.In this case, the patient presents with a history of chronic, constant neck pain. Records include radiographic evidence of degenerative disc disease at C5-6 with right neuroforaminal stenosis and 3 mm degenerative retrolisthesis. The patients treatments have included medications, physical therapy, acupuncture, and chiropractic treatment, and a neuromuscular electrical stimulator (CPT code E0745) has been prescribed for diagnoses of cervical disc degeneration and spondylosis. Current evidence based medical literature, however, does not support the use of electrical muscle stimulation for patients with chronic neck pain. Therefore, the requested C-Stim Unit neuromuscular stimulator (CPT code E0745) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device is not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.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:  The parent of an enrollee requested an inpatient hospital stay for treatment of the enrollees gastroenteritis, dehydration, acidosis, and hypoglycemia. Findings:  The physician reviewer found that, the patient was noted to have persistent emesis and diarrhea at the time of presentation. She was severely dehydrated on initial emergency department evaluation. According to the medical literature, severe dehydration and intractable vomiting are indications for hospital admission. Given that this patient had severe dehydration and persistent vomiting, inpatient therapy with intravenous and oral hydration was warranted. Current clinical practice guidelines suggest that discharge may be possible once sufficient rehydration has occurred, intravenous fluids are not required, oral intake equals or exceeds losses, medical follow-up is available, and adequate family teaching has occurred. In this case, the patient received intravenous fluid up until the day of discharge and was noted to continue to have significant stool losses. For these reasons, the inpatient hospital stay was medically necessary on the dates of service in question for treatment of this patients medical condition. 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 pediatrics and pediatric critical care 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 reimbursement for the skilled nursing facility (SNF) services rendered at Cedar Crest Nursing and Rehabilitation Center for treatment of the enrollees stage IV epidermal growth factor receptor (EGFR) mutation positive non-small cell lung cancer and a spindle cell cancer of the porta hepatitis/duodenum. Findings:  The physician reviewer found that the patients advanced metastatic cancer and resulting symptoms were appropriate for inpatient palliative care or hospice care, but did not require the skilled nursing services provided at the SNF level of care. The nursing notes state that the patient required significant help with her activities of daily living, received enteral feedings, and was monitored by nursing, but did not receive physical therapy or occupational therapy. As this patient did not receive skilled nursing services that can be provided only as inpatient, the patient could have been transferred to inpatient palliative care or hospice care. Thus, the SNF services rendered at Cedar Crest Nursing and Rehabilitation Center were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld

The patient is a 58-year-old male who has advanced osteoarthritis in both knees. He has been treated with Synvisc injections and obtained significant pain relief. He has requested authorization and coverage for further Synvisc injections. The Health Plan has denied this request indicating the requested therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The patient has already received two courses of Synvisc injections. There is no medical justification for greater than two courses of Synvisc injections. There is no peer-reviewed medical literature supporting additional Synvisc injections in this clinical setting. Furthermore, additional injections of Synvisc are contrary to FDA recommendations. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested substance abuse services for treatment of his substance abuse.  Findings:  The physician reviewer found that based on review of the submitted medical records, this patient was in marked denial of the severity of his chemical dependence. The extent of the patients condition interfered with his ability to function at the workplace and required intervention. He was showing medical consequences of his illness such that a relapse would exacerbate his physical condition if not stabilized in a structured setting. As such, continued residential treatment level of care was medically necessary through the date indicated. Although the patient, transitioned to PHP level of care the following day, the records indicate he was sufficiently stabilized at that time to transition to an outpatient level of care, as he was no longer in denial of his condition and was compliant with treatment. Thus, the residential treatment center services provided from the time frame specified were medically necessary for treatment of the patients medical condition. However, the substance abuse treatment services provided from the time frame specified could have taken place in a more normative setting at home with the assistance of community services and therefore were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Retin-A for treatment of the enrollees adult acne. Findings: The physician reviwer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. In the treatment of acne, topical retinoids, such as Retin-A, are standard of care. Retinoids are the core of topical therapy for acne according to the guidelines of care of the American Academy of Dermatology. In this case, treatment with the topical medication Retin-A is indicated for treatment of the patients acne. Accordingly, the request for Retin-A has been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 female enrollee has requested an Omnipod insulin management system (tubeless system)for treatment of her diabetes (type I). Findings:  The physician reviewer found that the submitted records do not substantiate the medical necessity of the Omnipod pump. Other than the fact that the Omnipod pump does not require a catheter which can be pulled or caught, there is no published literature or evidence that the Omnipod pump is superior to a standard insulin pump as far as controlling insulin levels. As such, although the Ominipod pump would be easier to use, it is not necessary from a medical standpoint for treatment of this patients type I diabetes. The ability to participate in sports and exercise can be an important part of diabetes treatment. However, how to best accommodate this has not been well-studied. For patients on pumps, the options depend upon whether the sport is contact in nature. For contact sports, the connecting tubing and pump can be unclipped from the insertion site, provided that it is not left off for more than one hour at any time. Given that blood glucose levels may rise after doing this, this rise can be pre-empted by giving the next hour basal rate amount as a bolus before disconnecting it. However, when the sports activity lasts longer than one hour, the better alternative is to leave the pump in place at a lower temporary basal rate than usual, and to secure it by extra taping. As such, the patients current pump does not preclude her from participating in sports and exercise activities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a computed tomography (CT) angiogram of the heart for evaluation of her medical condition.   Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. Most recently, the PROMISE trial found no clear advantage for coronary CTA in low to intermediate risk patient groups. In addition, the American College of Cardiology Foundation guidelines suggest as a class I recommendation the use of standard exercise stress testing if the patient is able to exercise, or stress testing with stress-echo or nuclear imaging if the patient is unable to exercise or has an abnormal baseline ECG. Standard treadmill or nuclear stress imaging in the low to intermediate risk groups is a class I recommendation. Therefore, based on current guidelines, the request for CT angiogram of the heart is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  The physician reviewer found that this patient meets National Comprehensive Cancer Network (NCCN) guidelines for genetic testing based on a first degree relative. The patients mother was diagnosed with  breast cancer under the age of 50. Additionally, the patient also had other close relatives who were diagnosed cancer.  The patients paternal grandfather was diagnosed with male breast cancer and a paternal aunt was diagnosed with gastric cancer. Both sides of her family have a high likelihood to have passed on a gene that would make this patient susceptible to breast and ovarian cancer and possibly other cancers. The recent introduction of multigene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at risk patients and their families. Based on next generation sequencing technology, these tests simultaneously analyze a set of genes that are associated with a specific family cancer phenotype or multiple phenotypes. When more than one gene can explain an inherited cancer syndrome, then multigene testing may be more effective. All told, the panel gene testing was likely to have been more beneficial than the other standard options available for the evaluation of this patient. Final Result: Two of the three  reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 parent of a seven-year-old female enrollee has requested speech therapy for treatment of the enrollees speech and language delays.  Findings:  The physician reviewer found that a thorough review of the literature reveals there are no outcome studies or randomized, controlled studies demonstrating that individual speech therapy improves pragmatic speech and communication in patients with autism. Furthermore, the majority of the goals outlined for this patient are educationally based, such as improved receptive vocabulary, expressive vocabulary and expressive communication. While pragmatic goals are also identified, the patient has not shown significant gains in these areas and such goals could appropriately be incorporated into an individualized education plan (IEP) and addressed through the school system.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-year-old female enrollee has requested bariatric lap band surgery for the treatment of the enrollees obesity. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient does not meet the generally accepted BMI criteria (BMI greater than 35) for adolescent bariatric surgery. In addition, the patient is eight years old and has not obtained near full growth stature. Furthermore, there are no randomized, controlled trials in the peer-reviewed literature which document the safety, efficacy and long-term outcome benefit of bariatric surgery for patients of this age with a BMI below 35. Further, there is no peer-reviewed evidence demonstrating that bariatric lap band surgery is a well-established and effective treatment modality for children with insulin hypersecretion.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested laparoscopy and magnetic resonance imaging for evaluation of her abdominal pain and pelvic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is no indication for the requested magnetic resonance imaging or laparoscopy in this clinical setting.  Per the submitted records, the patient has undergone an appropriate and complete work-up for her abdominal and pelvic pain.  She has been examined, and laboratory and ultrasound studies have been obtained.  In addition, she had a normal colonoscopy and CT scan of the abdomen to rule out intra-abdominal pathology.  The current medical evidence does not support the requested services in this patients case.  All told, the requested laparoscopy and magnetic resonance imaging are not medically indicated for the evaluation of this patient.