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

A 58-year-old male enrollee requested one day subacute detoxification services, subacute rehabilitation for six days, and partial hospitalization program (PHP) services for 32 visits for medical treatment of his opiate withdrawal with diagnosis of chronic pain syndrome.   Findings:  The physician reviewer found that based on the available medical records, the patient was not displaying withdrawal symptoms. His medications were prescribed by his providers and he was not taking them in a manner which would indicate the potential for clinically significant withdrawal that would require inpatient treatment with 24-hour medical and nursing monitoring. The patient did not meet the American Society of Addiction Medicine (ASAM) criteria for PHP or subacute residential treatment. All told, one day subacute detoxification services, subacute rehabilitation for six days, and PHP services for 32 visits were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 68-year-old female enrollee has requested for occupational therapy for treatment ofher diagnosed with weakness of arm, diabetes mellitus, hyperlipidemia, lumbosacral sprain, strain of hip, strain of thoracic region, osteoarthritis of the knee, peripheral edema, adjustment insomnia, carpal tunnel syndrome and weakness of hand.   Findings:  The physician reviewer found that there are no clear indications or goals for occupational therapy. There are no indications of significant current impairments in her activities of daily living that would be amenable to interventions by occupational therapy.  All told, the requested occupational therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested inpatient hospital care for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this patients case, she was adherent with her mood stabilizing and antipsychotic medications.  She was switched from oral to intramuscular Haldol on the said date.  Neither the physician notes nor the nursing notes document that the patient posed an imminent risk to self or others.  The medical records do not establish the need for continued inpatient services as the said date.  All told, inpatient hospital care from the date in question forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an additional 10 hours per week of applied behavioral analysis (ABA) services (for a total of 40 hours) for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for an additional 10 hours per week of ABA services (for a total of 40 hours per week) is medically necessary for treatment of the patients medical condition. ABA is a medically necessary intervention for the treatment of autistic children and remains one of the most evidence based interventions available. In this case, a total of 40 hours per week of ABA therapy has been recommended to address non-compliance, and restrictive and repetitive behaviors. A treatment plan has been developed that is consistent with the patients health needs and consistent with the diagnosis of an autism spectrum disorder. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In addition, the Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Given the medical necessity of ABA therapy for children with autism and correlation between treatment outcomes and intensity, the request for 40 hours of ABA therapy per week is medically necessary for treatment of the 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 board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma injections (CPT 0232T).Findings:  The physician reviewer found that based on the available evidence, patients undergoing meniscal repair with platelet-rich plasma augmentation experience similar clinical outcomes at midterm follow-up when compared with conventional meniscal repair. However, additional studies are needed to determine the efficacy of meniscal repair augmented with platelet-rich plasma. Shahid and Kundra concluded that there is some evidence to support the utility of platelet-rich plasma for selected indications in osteoarthritis, ligament, tendon and meniscal injuries of the knee. The authors cautioned that before widespread use can be recommended, high-quality prospective randomized studies are required. Belk and colleagues reported that there are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing meniscal repair with versus without platelet-rich plasma augmentation. This patient sustained a radial tear of the lateral meniscus. She underwent right knee arthroscopic lateral meniscus repair on 5/13/20. In the post-operative period, two platelet-rich plasma injections were performed to the right knee. The provider indicated that these injections were performed to maximize the biologic healing potential of this complex tear. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of platelet-rich plasma for this patient. Therefore, the platelet-rich plasma injections (CPT 0232T) were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the platelet-rich plasma injections (CPT 0232T) were not 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 not likely to be more beneficial for treatment 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 orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested gastric electrical stimulator for treatment of her diabetic gastroparesis. Findings:  Two physician reviewers found that the requested device is not likely to be more effective than other treatment options.  There is a lack of support for the requested gastric electrical stimulator in this clinical setting.  Per the current medical literature, there is a paucity of evidence supporting this device.  The gastric electrical stimulator has not been shown to consistently improve gastric emptying.  All told, the requested gastric electrical stimulator is not likely to be more efficacious than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested a PET scan for an evaluation of her gait/mobility disorder. Findings:  Two physician reviewers found that the peer-reviewed literature showed little support for the use of PET scans in patients with known or suspected Parkinsons or related movement disorders. The use of PET scans in patients with movement disorders is limited to those patients who are participating in a clinical trial. At this time, there is a lack of randomized, well-controlled studies to support PET scans in patients with movement disorders. It has yet to be shown that the proposed study provides clinically useful information for evaluation and management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Foundation One) for evaluation of the enrollees anaplastic astrocytoma. Findings:  2/3 of the physician reviewers found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the testing at issue was 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 62-year-old female enrollee has requested an Oxylite System, a lightweight portable oxygen delivery system for the treatment of her breathing problems.   Findings:  The physician reviewer found that the Oxylite System is requested for out-of-home use, such as for gardening and animal care on the patients ranch.  There is no evidence that the patient cannot use a standard oxygen system for routine activities of daily living.  Consequently, it appears that a lightweight oxygen system is a convenience item here.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gastric bypass for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. Although this patient is morbidly obese and has failed dietary efforts, she does not meet criteria for the requested procedure for failure to document attendance to a weight loss program of at least three sessions per month for six months. In addition, she does not have documentation of six monthly physician supervised dietary efforts. For the reasons stated, the requested services are not medically necessary in this clinical setting. 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 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

A 23-year-old female enrollee has requested for inpatient services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services and the American Psychiatric Association (APA) guidelines, this patient received medically appropriate services at the least restrictive level of care possible throughout her treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested MetaNeb system and percussion treatment for the enrollees medical condition status post subdural hematoma.  Findings: The physician reviewer found that the records do not indicate that this patient does has cystic fibrosis or bronchiectasis. He does have neuromuscular disease but there is no documentation that the use of the requested device in this patient with paralysis would improve his long-term health outcome. As noted by the provider, the patient cannot move his extremities. Chest physical therapy with suctioning through the tracheostomy is considered the standard of care for this patients treatment given these findings. Accordingly, the requested MetaNeb system and percussion treatment in a long-term acute care facility is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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 45-year-old female who has been treated by her chiropractor for bilateral neck, right shoulder, elbow, and hand pain. She has found relief with chiropractic treatment but requests two treatments a week until she further improves from her chronic problem. The records reveal ten chiropractic treatments have already been provided. Her chiropractor has given her a broad diagnosis of cervicalgia and muscle spasm. The treating record does not show a treatment plan with goals or development of a home program.This patient has a history of chronic dislocation of her right shoulder that improved with shoulder surgery. A recent cervical x-ray revealed facet arthropathy, hypertrophic changes at C5-6, and hypoplastic development of her C1 area. The Health Plan has denied authorization and coverage for continuing chiropractic care based on lack of medical necessity.Research reveals that specific exercises concurrent with chiropractic care yields a superior result. Two months of chiropractic care have been provided for this patient. Upon review of the record, an x-ray report dated 7/29/04 reveals a hypoplastic development of the posterior arch of the atlas vertebra (C1). Congenital abnormalities of this area of the spine are uncommon yet very significant relative to chiropractic care. Manipulation is an absolute contraindication for patients such as this patient who are at risk of atlantoaxial medical subluxation or dislocation. Provocative physical examination procedures of her cervical spine must be performed with full knowledge of her anomaly and potential instability. The integrity of her transverse ligament may be compromised in the maldevelopment process. Based upon the radiographic findings, continuing chiropractic care is contraindicated in this patient. 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

The parent of a one-year-old male enrollee has requested coverage for a cranial molding helmet for treatment of torticollis and plagiocephaly.  Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface, such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy, for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning. Although rare, some cases are severe enough to require surgery for correction (Gupta, et al; Graham, et al). Although positional head deformity is generally not a life-threatening condition, up to 10% of infants may have permanent deformity with subsequent complications (Biggs). Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible. In 2003, the American Academy of Pediatrics (AAP) published prevention and management guidelines for positional skull deformities in infants (Persing, et al). According to Graham and colleagues, for those infants who do not make progress with repositioning and tummy-time, with severe persistent brachycephaly (CI greater than 90%) at age 5 months, use of an orthotic helmet will correct the brachycephaly and any associated plagiocephaly. For infants with extreme occipital flattening, prolonged treatment may be necessary. This patient has abnormal head shape and torticollis that has been treated conservatively with repositioning, neck exercises, and physical therapy without improvement. Anthropometric measurements indicate significant brachycephaly with some degree of plagiocephaly. At this patients age, a cranial molding orthosis is essential to offer the best chance at normalizing his head shape. A cranial molding orthosis is thus medically necessary and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an office consultation with a pain management specialist. The American Academy of Family Physicians guidelines state that providers should provide patient-centered care to those with chronic pain or dependence on opioids, and should work with other health care professionals to provide multidisciplinary care. The management of chronic pain is complex and often benefits from consultation with specialists in pain management strategies. In this case, the patient has multiple sites of pain that require further evaluation and treatment by pain management. The enrollee has been evaluated by neurosurgery and found not to be a candidate for surgical intervention. Therefore, the requested office consultation with a pain management specialist is well supported by medical literature as medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in family 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested for computed tomography perfusion and carotid angioplasty and stenting for treatment of her severe bilateral supraclinoid internal carotid artery stenosis. Findings:  Three physician reviewers found that there is a lack of large, scientific studies on intracranial stenosis and its treatment by angioplasty and stenting that shows evidence of its safety and efficacy. The studies address symptomatic disease. This patient does not have symptomatic cranial disease. Her symptoms have been deemed non-focal by her neurologist. At this time, there is a lack of supportive literature regarding computed tomography perfusion imaging, and there is inadequate published evidence showing that it improves outcome.