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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychotherapy. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. The guidelines provide no defined frequency or duration for the amount of psychotherapy required for each patient. However, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature indicates that in unrestricted therapies, each additional psychotherapy session has a diminished effect. An article report that, at least in unrestricted therapies, the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. These results are consistent with previous studies.  The documentation provided indicates the patient has had extensive psychotherapy with weekly sessions since 2013. Additionally, the documentation of the type of therapy performed during the dates in dispute is sparse and the type of therapy appears to be unstructured supportive psychotherapy.  In this case, there is a lack of support in the documentation provided as well as in the medical literature to support the medical necessity for the weekly psychotherapy sessions in dispute. Therefore, the patients psychotherapy services 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 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: Overturned

The patient is a 42-year-old female with papular acne and rosacea. She had been treated previously with Plexion cleanser and Metrolotion. When Retin-A Micro 0.04% was added to her treatment program, the rosacea is reported to have improved considerably. The patients request for authorization of Retin-A Micro 0.04% was denied by the Health Plan based upon a determination that the medication is not medically necessary.Retin-A Micro is widely prescribed by dermatologists for the treatment of acne rosacea. Several studies have been conducted and the efficacy of treatment for patients such as this one is well documented. In fact, many standard textbooks of dermatology recommend this treatment. There is no question that Retin-A Micro has been beneficial for the patient and its continued use is medically appropriate. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 60 tablets per month for treatment of the enrollees chronic low back pain. Findings:  The physician reviewer found that not all non-opioid treatment options have been utilized for management of this patients pain. In addition, no mention of behavior therapy has been documented despite much research to support its use. The recent emergency room diagnosis of drug overdose and another recent occasion of the patient running out of Norco early support the need for services by a psychiatrist or addiction medicine for opioid medications. Moreover, pure mu agonists are not considered evidence-based treatments for fibromyalgia and may actually cause adverse effects in fibromyalgia patients.  Final Result: The reviewer determined that the requested medication is 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 anesthesiology with sub-specialty certification in pain 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 parent of an enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The progress notes indicate that the patient was cooperative in treatment.  She was noted to be providing and accepting feedback in group therapy.  She was not displaying dangerous behavior during her stay.  There was no notation of severe mood symptoms or psychosis.  She was not noted to be aggressive with peers or staff during her stay.  The records do not indicate that the patient had symptoms that would have necessitated residential care.  It appears that her treatment goals could have been managed in a less restrictive setting.  The records do not indicate that the patient had attempted or exhausted intensive outpatient services prior to her residential treatment center admission.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  There is a lack of support for the services at issue in this clinical setting.  All told, residential treatment center services  were not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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

The parent of a 13-year-old male enrollee has requested acupuncture for treatment of the enrollees cerebral palsy and back pain. Findings:  The physician reviewer found that there is a lack of evidence in the medical literature demonstrating that acupuncture is superior to standard therapies for the treatment of back pain for patients with cerebral palsy.  The articles by Zhang and colleagues and Liptak noted some benefit to acupuncture in reducing spasticity and tone. However, both articles note that further research is needed before acupuncture can be endorsed. This patient has been offered standard treatment to treat his pain, including physical therapy.  Physical therapy is considered standard of care for pain associated with muscle spasm for both chronic back pain and cerebral palsy.  In this patients case, acupuncture is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee requested reimbursement for a custom knee brace.  The Health Plan denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees left knee status post anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that although the use of a brace following ACL surgery is common practice, the scientific data to support its utility is limited. In the medical literature, Birmingham and colleagues found no difference when comparing the use of a brace and a neoprene sleeve. Further, McDevitt and colleagues concluded that in a young, active population, following ACL reconstruction, no difference was observed in clinical outcomes, with or without brace use. Similarly, Wright and Fetzer found no evidence that pain, range of motion, graft stability, or protection from injury were affected by brace use. At two year follow-up, there is no difference in function or laxity with rehabilitation without use of a brace (Brandsson, et al). Since the records do not document the presence of instability or another clinical justification for a custom knee brace following ACL reconstruction, the device at issue was not medically necessary and the Health Plans denial was therefore appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested partial hospital program (PHP) care for treatment of her behavioral health condition. Findings:  The physician reviewer found that the records submitted do not establish medical necessity for the PHP services provided on the dates of service at issue as they do indicate that the patient required these services. The records indicate that the patient was seen for three one-and-one half-hour group therapy sessions, along with one or two physician visits during the time period in question. PHP services typically are a minimum of 3-4 hours daily. The patients high GAF score, along with the physicians note and treatment plan, indicated that the patient was essentially in or close to complete remission. The patient presented with diagnoses of panic disorder and bipolar disorder. National practice guidelines indicate that hospitalization or partial hospitalization program services are only required for very severe cases of panic disorder with agoraphobia, when administration of outpatient treatment has been ineffective or is impractical. In this patients case there was no evidence submitted indicating that outpatient treatment had been ineffective or impractical for her. To the contrary, outpatient treatment appears to have been very effective as evidenced by the patients near or complete remission. Moreover, American Psychiatric Association guidelines do not indicate that PHP services are appropriate or medically necessary for the treatment of patients with bipolar disorder who are in remission.
Appeal type: Medical Necessity
Decision: Upheld

A twenty-two year-old female diagnosed with polysubstance dependence is requesting authorization of Phase I Outpatient Program for Chemical Dependency.  Reviewers Findings:  The reviewing physician found that the treatment plan recommended by the Health Plan for weekly individual therapy may prove to be more beneficial than additional substance abuse treatment.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a high-efficiency particulate air (HEPA) filter. As noted by Kimura, HEPA filters capture greater than 99% of 0.3 micron diameter particulates in a laboratory setting. This type of filter has multiple industrial applications, including in the hospital setting. A HEPA filter can also be appropriate for patients in the community with profound neutropenia to mitigate the risk of conditions such as aspergillosis. In addition, patients with asthma or allergies whose symptoms persist despite first-line interventions can benefit from placement in a controlled environment where an air purifier with HEPA filter can work to purify the ambient air while minimizing the ongoing intrusion of new airborne particulates. However, the use of HEPA filters outside of controlled clinical settings has not been established. Factors such as open windows, community population density, pets and the presence of flowering plants significantly more impactful with respect to microbial profiles in the household setting than HEPA filters. In this patients case, there is no documented medical indication for the HEPA air purifying system and extra filter provided. The patient is at increased risk for respiratory complications such as aspiration pneumonia, community-acquired pneumonia, atelectasis, and pulmonary embolus due to her underlying conditions, which include cognitive impairment, dysphagia, safety awareness deficits and dysmobility. Based on the available documentation and current medical literature, the use of a HEPA filter is not supported to improve this patients clinical, functional, or other health outcomes. For these reasons, the HEPA filter was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the device at issue was 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: Overturned

The parent of a four-year-old male enrollee has requested anakinra (Kineret) for treatment of the enrollees systemic juvenile idiopathic arthritis.   Findings:  Two physician reviewers found that there is adequate evidence in the peer-reviewed medical literature including appropriately designed studies, case series, and case reports to support the safety and efficacy of Kineret in the treatment of patients with soJIA. This patient has already been started on Kineret and has responded with symptomatic improvement and ability to reduce his need for steroids. All told, the requested medication is supported as likely to be more beneficial for treatment of this patients medical condition than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure. Findings:  Two of the three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. In sum, the LINX procedure is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in gastroenterology 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: Overturned

A 56-year-old female enrollee has requested for spinal fusion surgery for treatment of her spondylolisthesis.  Findings:  The physician reviewer found that applying the Milliman Care Guidelines, this patient meets the criteria for the requested surgical intervention given her severe and progressive and worsening pain, failure to respond to conservative measures greater than three months and significant functional impairment. Approval of the requested TLIF instrumented fusion at L3-S1 for management of this patients condition is also consistent with the findings published by Resnick and colleagues guiding fusion in patients with stenosis and spondylolisthesis. All told, the requested surgery has been established as medically necessary in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Mobi-C level total disc replacement for treatment of her medical condition. Findings:  Two physician reviewers found that evidence-based, peer-reviewed literature supports the use of two-level contiguous cervical artificial disc replacement as an option over anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease.  This patient presents with persistent severe neck and upper extremity pain and progressive weakness.  Clinical examination findings are consistent with two-level contiguous cervical degenerative disc disease with moderate to severe stenosis.  There is evidence of comprehensive non-operative treatment without sustained benefit.  The use of two-level artificial disc replacement will allow for motion preservation, which would be sacrificed with the use of fusion. Therefore, the requested Mobi-C two-level disc replacement is likely to be of greater benefit than other treatment options.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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: The patient has requested reimbursement and prospective authorization and coverage for hyperbaric oxygen therapy (CPT 99183 and HCPCS G0277) for 30 total treatments of 90 minutes (four segments per treatment) once daily for five (5) days per week. The submitted documentation supports the medical necessity of a portion of the services at issue. Hyperbaric oxygen therapy has been approved by the U.S. Food and Drug Administration for treating sudden hearing loss. The American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline on sudden hearing loss listed hyperbaric oxygen therapy, in conjunction with steroid therapy, as an option for either initial or salvage therapy, depending on the timing of symptomatic onset. In this case, hyperbaric oxygen therapy was initiated five days after symptom onset, so it would be classified as initial therapy. The patient received oral steroids and three intratympanic injections of steroids as well, with the oral steroids and the first injection received prior to hyperbaric oxygen therapy initiation. There is moderate peer-reviewed evidence to support limited use of hyperbaric oxygen therapy in combination with steroids as initial therapy for idiopathic sudden sensorineural hearing loss. Researchers concluded that there was no significant difference in hearing gain between patients with idiopathic sudden sensorineural hearing loss treated with intratympanic steroids/hyperbaric oxygen therapy and those treated only with intratympanic steroids. Researchers did find a benefit for patients treated with intratympanic steroids/hyperbaric oxygen therapy in combination, with a stronger effect in those with severe to profound sudden sensorineural hearing loss, such as this patient. Researchers noted that there is no universally accepted hyperbaric oxygen therapy protocol with proven effectiveness, although a 10-day to 20-day treatment duration (90-minute session each day) has been recommended by the Undersea and Hyperbaric Medical Society. Therefore, a 20-session hyperbaric oxygen therapy course was and is medically necessary to treat the patients hearing loss. Final Result: The reviewer determined that a portion of the services at issue was and is 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 otolaryngology 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 Axumin positron emission tomography (PET) scan. The current medical evidence supports the requested services in this clinical setting. This patient has a history of prostate cancer, and the records noted increasing PSA levels. Axumin PET scanning is utilized to localize recurrent disease in patients with a history of prostate cancer with increased PSA. The sensitivity of Axumin PET scans increases with increasing PSA values. In this case, there is significant clinical suspicion for disease recurrence due to increasing PSA values as well as MRI findings. The Axumin PET scan is a sensitive examination to detect the site of suspected recurrence. Therefore, Axumin PET scan 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 diagnostic radiology 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.