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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center (RTC) services for treatment of his medical condition.  The records indicate that on the dates at issue, the patient was not a danger to himself or others. He had no coexisting medical conditions, he did not show aggression or violence, and he was compliant with his medication regimen. He was cooperative with staff and respectful. His social skills were no longer problematic and he no longer required one-to-one supervision and only received prompting for daily living skills. There was no evidence to suggest that returning the patient to the community would result in decompensation or exacerbation in his prior symptoms that would result in the need to continue RTC level of care. He had improved and no longer required 24-hour nursing or medical supervision; psychotherapy did not need to be delivered in the RTC setting. He could have been treated at a less restrictive level of care. Thus, the RTC services on the dates at issue were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for acupuncture services. Clark and Tighe report, There is evidence supporting the effectiveness of acupuncture for plantar heel pain (PHP). This is comparable to the evidence available for conventionally used interventions, such as stretching, night splints or dexamethasone. Therefore, acupuncture should be considered in recommendations for the management of patients with PHP. Vickers and colleagues note that, Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. In this case, the patient reported benefits from prior acupuncture, but the records did not document pre-acupuncture and post-acupuncture baselines for comparison purposes, the total number of acupuncture sessions completed, and measurable, progressive, significant, or objective functional improvement. The documentation did not demonstrate significant medication intake reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. Given that measurable, progressive, significant, objective functional improvement has not been documented, the services at issue were not and are not medically indicated. Therefore, acupuncture services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue 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 acupuncturist, board certified in oriental 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Neuroendocrine tumors are diverse group of neoplasms typically treated with radionuclide therapy. In the present case, the patient had a neuroendocrine tumor that grew to cause airway obstruction. She underwent treatment that included radiation and placement of a tracheostomy tube. Computed tomography (CT) imaging demonstrated a persistent paratracheal mass surrounding the tracheostomy. This precludes decannulation or use of a Passy Muir valve for speech. The patient has been undergoing rehabilitation services while at the SNF. Her function has fluctuated, but she has plateaued at a level where she requires assistance for activities of daily living, including lower body self-care, and contact guard assistance for basic mobility. The records do not support that the patient requires ongoing medical, nursing, or rehabilitative care at the inpatient SNF level of care. Therefore, the SNF services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee requested platelet-rich plasma injections for medical treatment of his right medial epicondylitis.  Findings:  Three physician reviewers found that the requested services are not likely to be superior over other treatment modalities.  Randomized controlled trials have not found superiority of platelet-rich plasma injections over standard available treatments such as steroid injections.  In addition, the few randomized controlled trials supporting platelet-rich plasma injections have relatively short-term follow-up.  All told, the requested platelet-rich plasma injections are not likely to be of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic testing. Researchers note that the diagnostic evaluation of a patient with suspected postural orthostatic tachycardia syndrome (POTS) requires a careful clinical history and examination involving an assessment of pupillary responses, an evaluation for sudomotor and vasomotor signs, and an assessment for joint hypermobility,  laboratory testing, and autonomic testing. The author further notes that the purpose of autonomic testing is to confirm a POTS diagnosis, exclude other causes of orthostatic intolerance, and provide for characterization of POTS into neuropathic and hyperadrenergic subtypes. Researchers found that a large subset of POTS patients have sudomotor abnormalities which are typically patchy in distribution but do not correlate with other tests of autonomic function. In this case, the patient presented to her provider. The records noted she was status post COVID-19 infection with a past medical history of optic neuritis. The patient reported persistent headaches and atypical chest pains, and her neurologist recommended testing for autonomic dysfunction. In this clinical setting, testing for autonomic function was important in the diagnostic evaluation of this patient and had important therapeutic implications. Therefore, autonomic testing was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the autonomic testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 56-year-old male enrollee requested anesthesia (monitored anesthesia care (MAC)) for treatment of his average-risk screening for colon cancer.  Findings:  The physician reviewer found that the documentation submitted for review does not support that the risk factors warranting MAC were present in the patients case, nor did his pre-sedation evaluation raise concern for intolerance to conscious sedation. In sum, the MAC was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested procedure 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 procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Prometheus Anser ADA testing for evaluation of his medical condition.   Findings:  Two physician reviewers found that the current medical evidence does not support the services at issue in this patients case.  The use of Anser ADA has not been clinically proven to improve patient clinical outcomes. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management.  In sum, the superior effectiveness of Prometheus Anser ADA testing has not been demonstrated.   Final Result: Two 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a stress echocardiogram. Based on the submitted records, this patient presents with increased coronary risk in addition to symptoms of palpitations and exertional dyspnea concerning for an anginal equivalent and/or left ventricular dysfunction. In this circumstance, further evaluation to assess for left ventricular dysfunction and coronary ischemia is medically appropriate.  An imaging stress test is appropriate to evaluate for both left ventricular dysfunction and coronary ischemia in the same procedure. Stress echocardiography is indicated based on the patients symptoms, regardless of upcoming low risk non-cardiac hysterectomy surgery. Current guidelines endorsed by several national organizations consider stress echocardiography appropriate in this setting. Therefore, the requested stress echocardiogram is medically necessary for the evaluation of this patient.  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 internal medicine with sub-specialty 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: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested skilled nursing services eight hours per day for treatment of the enrollees multiple medical conditions.   Findings:  The physician reviewer found that this patient is medically fragile with very complex medical problems and the potential for severe decompensation. He requires round-the-clock diligence to prevent the myriad of complications that could occur. He has been assessed with chronic lung disease and reactive airway disease and requires aggressive pulmonary care, including frequent suctioning, breathing treatments, and Vest therapy. He also occasionally requires supplemental oxygen. He is at increased risk for aspiration because of gastroesophageal reflux and intractable seizures, and has been hospitalized multiple times with this diagnosis. While trained unskilled caregivers can safely administer routine enteral medications and feedings, only caregivers with professional training and expertise can detect subtle changes in respiratory status and respond with appropriate adaptations to the treatment regimen, thus preventing progression to more severe respiratory compromise. In addition, this patient requires frequent suctioning, medication administration, skin care, and therapeutic manipulations.This level of care requires experience and attention to detail so that needs are met, problems recognized promptly, and treatment administered in a timely fashion. While trained family members are often capable of assisting with care of children with this degree of complexity, skilled nursing is essential to provide adequate care. As such, I find that the skilled home nursing services the patient received during this period of time were medically appropriate and necessary for this patient. Furthermore, the submitted documentation demonstrates the patient continues to require this level of care, and therefore, the request for ongoing skilled nursing services at a frequency of eight hours per day is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested a hydrogen breath test for evaluation of the enrollee, who has a history of constipation. Findings:  The physician reviewer found that this patient has chronic constipation which is adequately documented in the medical records supplied for review. The submitted documentation indicates that her response to treatment for small intestinal bacterial overgrowth has been unsuccessful. However, her symptoms are more likely due to chronic constipation. Patients with chronic constipation can demonstrate an abnormal hydrogen breath test that can be difficult to interpret from the results seen for small intestinal bacterial overgrowth. Information in the medical records does not support the diagnosis of small intestinal bacterial overgrowth. If this patients breath testing is positive, it may be positive due to chronic constipation.  This would explain why prior treatment of small intestinal bacteria overgrowth has been ineffective.  The current medical evidence does not support the requested testing in this clinical scenario.  The results of another hydrogen breath test are not likely to alter the patients therapeutic options.  All told, the requested hydrogen breath test is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested physical therapy for treatment of his medical condition. Findings: The physician reviewer found that the patient sustained a traumatic fracture requiring surgery and months of protected weight bearing.  He has had extensive physical therapy and is now functioning at a high level although he has not returned to all his pre-injury activities. The records show he continues to have a deficit of ankle range of motion. He is pain free. The literature on physical therapy for the patients fracture is limited. The reviewers describe a case of a young athlete with a roughly similar fracture who was aggressive in return to activity, sustaining a non-union and second surgery at 22 weeks after initial fixation surgery. The authors note Prognosis for return to sport in a tibia-fibula fracture due to a soccer injury is approximately 40 weeks, however many factors can influence the outcome. The patients fracture is comparable in severity and a 40 week recovery is a reasonable expectation. At this point the mainstay of treatment is independent stretching and strengthening with graded return to activities. Due to the fracture, the patient may not regain full range of motion or have the ability to run as he did before the fracture. In this clinical setting, four additional visits of physical therapy are reasonable and medically necessary. These physical therapy visits will evaluate for the development of pathology requiring correction and to adjust his exercise regimen. In sum, a portion of the services at issue were and are medically necessary. Final Result: The reviewers determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The physician 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Orthovisc injection series in the right knee. Findings:  The physician reviewer found that the the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis of the right knee and lasting benefit from prior injections. Furthermore, the options are limited. The patient has chronic renal disease and is unable to take NSAIDs, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Orthovisc injection series in the right knee is medically necessary for the 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic services. Researchers compared the short-term effects of manipulative treatment to those from a therapeutic home exercise protocol for chronic cervical pain and found that both interventions improved function and pain after one week, with only marginal differences between the groups in favor of manipulative therapy. While the article referenced cervical pain, the findings may be applied to chronic back pain. In this case, while the patient has been referred for chiropractic care, the documented symptoms included midback pain, stiffness, and soreness, described as debilitating for one week, and did not note physical examination findings of limitations caused by pain. In this clinical setting, the requested services are not medically indicated. Therefore, chiropractic services 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 licensed D.C., board certified in chiropractic 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

A 48-year-old female enrollee has requested for the oxygen concentrator and/or oxygen for treatment of her Osler-Weber-Rendu syndrome. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the equipment at issue.  Per the submitted medical records, the patient has a history of known pulmonary arteriovenous malformations.  She is status post embolization. Per the documentation provided, there is no evidence of significant hypoxemia.  Additionally, there is no evidence of arterial oxygen desaturations which would require long-term oxygen therapy. Based upon the blood gases provided, long-term oxygen therapy is not medically indicated. The current medical evidence does not support the use of the equipment at issue in this clinical scenario.  All told, the oxygen concentrator and/or oxygen received from the date in question onward were not and are not medically necessary for the treatment of this patient.