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

Summary Reviewer 2

The parent of a 16-year-old female enrollee has requested authorization and coverage for ceftriaxone sodium injection. The Health Insurer has denied this request indicating that the requested medication is at investigational for the treatment of the enrollees Lyme disease. The physician reviewer found the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The diagnosis of chronic Lyme disease is controversial. This is due to the inability of clinicians to consistently and reliably diagnose this disorder via laboratory testing. In addition, most accepted practice guidelines suggest the maximum length of antibiotic therapy for Lyme disease is four weeks. This is even for those individuals who have late disease with neurological complications. In multiple studies there has been no benefit shown in patients who have received antibiotics for greater than 28 days compared to those who have not.  Moreover, long-term use of IV antibiotics carries significant risks including liver disease, anaphylaxis, and candidemia. The relation between CD8-CD57 cell counts/percentage and Lyme disease has been addressed sparsely in the medical literature despite anecdotal claims of these lymphocyte surface markers being an indicator of Lyme disease activity.  Furthermore, the majority of patients who have epidemiological, clinical, and laboratory evidence of Lyme disease only require 13 days of therapy, usually oral. As such, the continued use of ceftriaxone sodium injection is not likely to be more beneficial treatment than standard medical therapy in this clinical setting. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of an 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy provided from 1/1/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. A letter from the patients ABA provider recommends a number of goals designed to decrease the patients aggression. However, the patient has already been treated with extensive ABA therapy and still continues to exhibit aggressive behavior. In addition, the patient was taken out of public school because of his aggression, which may be problematic if therapy is attempted within a community setting. The additional tests and recommendations submitted for review do not support the medical necessity of the services at issue. This patient has a full scale IQ of 74 which would suggest he does have the intellect to learn from therapeutic sessions. However, his retention is limited and he has regressed to baseline at the completion of his prior ABA treatments. In addition, there is a lack of support in the medical literature for the additional testing performed. For the reasons provided, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 57-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/24/15.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 27-year-old female enrollee has requested authorization and coverage for E1399 durable 
medical equipment RT300 FES arm therapy system. The Health Insurer has denied this request 
and reported that the requested device is investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that a functional electrical stimulation cycle 
ergometer is not proven to improve function or other outcomes in the setting of this patients 
condition (relatively mild hemiparesis, sensory dysfunction and tone abnormalities related to a 
brain lesion that was resected in April 2021). A recent meta-analysis in the setting of subacute 
stroke by Ambrosini and colleagues did not find that functional electrical stimulation-induced 
cycling improved outcomes better than usual care for subacute stroke survivors. The use of this 
type of device is not an evidence-based component of non-progressive brain injury 
management, rehabilitation, or prevention of complications, as noted on multiple recent 
reviews. The device in question is not likely to be more beneficial for treatment of the patients 
medical condition than any available standard therapy, which would include, but not be limited 
to, occupational therapy, independent exercise and splinting, even if a full neurological and 
functional recovery is not expected to be elicited by these standard therapies. Therefore, the 
requested for E1399 durable medical equipment RT300 FES arm therapy system is not likely to 
be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient received platelet-rich plasma injections into the bands of plantar fascia of both heels to enhance healing and relieve chronic pain. Gonnade and colleagues compared injections of platelet-rich plasma with phonophoresis and kinesiotaping for chronic plantar fasciitis. The study concluded that therapeutic quality autologous platelet-rich plasma injection has regenerative effect with long and better efficacy in pain management of chronic recalcitrant plantar fasciitis than phonophoresis and kinesiotaping. The study by Shetty and colleagues compared platelet-rich plasma injection with corticosteroid injections. The conclusion was that both platelet-rich plasma injections and corticosteroids are safe and effective treatments for chronic recalcitrant plantar fasciitis. Both options for chronic plantar fasciitis showed superior results to placebo treatment. However, platelet-rich plasma injections showed longer-term results and less need for reinjection or surgery, which made platelet-rich plasma injections superior to corticosteroid injections. Thus, injection of platelet-rich plasma performed on 12/21/18 was likely to have been of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  A routine mammogram would have been sufficient in this clinical setting.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16 was not likely to have been more efficacious than other modalities for evaluating this patient.  Based upon the information set forth above, the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that the submitted records fail to demonstrate the superior efficacy of the services at issue. The current literature has not established that percutaneous tibial nerve stimulation is of greater benefit than standard methods of treating this patients condition. This patient may benefit from medications, hydrodistention, intravesical therapy and pelvic floor biofeedback. Per the records, first-line and second-line treatments have not been systematically trialed and exhausted. In sum, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was not likely to have been more efficacious than other available treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 27-year-old female insured has requested reimbursement for the respiratory virus panel 
testing (CPT 87633, 87798, 87798-59) provided on 7/21/22. The Health Insurer has denied this 
request indicating that the services at issue were considered investigational for evaluation of the 
insureds respiratory illness and shortness of breath. The physician reviewer found that the 
records reflect that the respiratory virus panel services performed on 7/2/122 in the emergency 
room identified a parainfluenza virus. However, the respiratory virus panel testing did not meet 
the American Thoracic Society criteria for this type of testing (Evans, et al.). Medical literature 
has indicated that respiratory virus panel testing is appropriate to test when there is a suspicion 
of immune compromise, a high risk of complications from the infection and when the testing 
could be used to direct therapy (Calderaro, et al.). In the case at hand, the patient presented to 
the emergency room with shortness of breath and cough and, just prior to the visit, reported not 
feeling well. Further, the patients medical records indicate that the patient had treated with 
amoxicillin  for  only  five  days  prior  without  symptom  improvement.  The  record  lacks 
documentation of concerning immune compromise, complication risk, or the need for the panel 
testing to direct therapy. Therefore, the respiratory virus panel testing (CPT 87633, 87798, 87798-
59) provided on 07/21/22 was not likely to have been more beneficial than any other available 
standard treatment for the evaluation of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 63-year-old female with psoriasis predominantly on her hands/feet-palmoplantar variety. She has requested authorization and coverage for Otezla. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology-National Psoriasis Foundation, patients who have psoriasis affecting between 3-10% (moderate) and greater than 10% (severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating physician with attention paid to patient comorbidities. Otezla is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis and has Level A evidence to support its efficacy. Given that the patient has documented evidence of moderate-to-severe disease, it would be medically appropriate to pursue this therapy. Therefore, Otezla is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 19-year-old female with a history of mood disorder and attention deficit/hyperactivity disorder. The patient was admitted to a residential treatment center on 2/04/15 due to worsening anxiety, family disturbances, low self-esteem, and depression. The patient was treated with individual, group, and family therapy along with medication management of fluoxetine. The patient has requested reimbursement for psychiatric residential treatment provided from 2/04/15 through 11/30/15. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patient met the following criteria based on the submitted records. In terms of risk of harm, the records support a score of 1. The patient did not have a history of suicide attempts. She did not have suicidal or homicidal ideation. With regards to functional status, the records support a score of 3. The patient was struggling to maintain good grades. The patient was able to maintain her activities of daily living. With regards to comorbidity, the records support a score of 3. The patient had comorbidities of attention deficit/hyperactivity disorder and borderline traits which adversely affected her mood.  In terms of environmental stress of the recovery environment, the records support a score of 3. The patient had interpersonal struggles in the home. This has had a significant impact on her living environment.  With regards to environmental support, the records support a score of 2. The patients parents were supportive of the patient and were willing to participate in treatment. In terms of resiliency, the records support a score of 3. The patient was seeing a therapist for a year. She had an equivocal response to therapy. With regards to acceptance and engagement, the records support a score of 2. The patient was cooperative with staff and would engage in treatment. Thus, the records support a composite score of 17.  Based on these criteria, the patient met criteria for an intensive outpatient program and could have been treated in a less restrictive environment. Thus, psychiatric residential treatment provided from 2/04/15 through 11/30/15 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 41-year-old female enrollee has requested reimbursement for MyRisk genetic testing performed on 1/24/17.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollee, who has a family history of cancer. The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  BRCA testing guidelines recommend BRCA testing for this patient who has a close relative with ovarian cancer.  However, this patient has requested reimbursement for the MyRisk panel. This is a 25-gene panel that includes BRCA testing, but also a variety of other suspected risk genes. Although many of these other gene mutations are of interest and are being studied, for the most part, they have as yet not been found to be significant enough to be the basis for clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from the major organizations.  Therefore, BRCA testing was likely to have been more effective than other methods of evaluating this patient.  However, the current medical evidence has not established the superior efficacy of the remainder of the testing performed. Therefore, a portion of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 59-year-old female who was admitted to residential treatment for worsening depressive symptoms on 1/05/20. At the time, she endorsed low mood as well as many neurovegetative impairments, including increased sleep, decreased energy and anhedonia. The physician reviewer found that based on the limited information noted above, the patient does not meet medical necessity criteria for residential treatment. There is no evidence of suicidality. There is no evidence of functional decline. There was no evidence of psychosis or disorganization.
The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
In terms of risk of harm, the records support a score of 2. She had a low risk of harm given lack of suicidality or self-injurious behaviors.
With regard to functional status, the records support a score of 3. The patient reported that she had not had employment for over a year.
In terms of comorbidity, the records support a score of 4. She has major medical comorbidity, including history of head trauma/closed head injury as well as stage IV vaginal cancer.
With regard to level of stress of the recovery environment, the records support a score of 2. Her recovery environment is minimally stressful based on the information provided. She reported a close relationship with her daughter.
In terms of level of support of the recovery environment, the records support a score of 2. The documentation noted that the patient had a psychiatrist and therapist.
With regard to resilience and treatment history, the records support a score of 3. She has seen may providers, without complete remission of her symptoms.
In terms of engagement and recovery, the records support a score of 2. The patient has been adherent with treatment plan, including medication.
Thus, her composite score is 18. Based on LOCUS criteria, she did not meet criteria for residential treatment level of care. Therefore, residential treatment provided from 1/05/20 through 1/09/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 29-year-old male enrollee has requested reimbursement for chiropractic modalities CPT codes (97012, 97110, 97140 and 99213) for the following dates: 1/22/16, 1/25/16, 1/27/16, 1/29/16, and 2/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and upper back pain. The physician reviewer found the submitted records do not demonstrate the medical necessity of the services at issue. There is no high grade scientific evidence to support passive physical modalities such as traction and massage/myofascial release to neck and upper back complaints as indicated in this case. The patient did make functional change with objective measures such as neck disability index and upper extremity functional scale. However, there is no evidence that the patient would not have made functional changes with only the approved services and not the adjunct therapies. Treatment dependence on passive modalities such as massage should be avoided. Only when there is evidence of a lack of effectiveness should relaxation massage be offered. Physical modalities such as specific neck exercises for range of motion and strengthening are also recommended. There is strong evidence that exercise programs are superior to therapies that do not include exercise. For the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 10-year-old male with a diagnosis of autism. The patients parent states that the 
patients therapy was terminated due to non-coverage, so no additional records are available. The 
patients parent has requested reimbursement and prospective authorization and coverage for 
occupational therapy. The Health Insurer has denied the services  at issue as not medically 
necessary. This denial is the subject of this appeal and determination. The physician reviewer 
found that on review of the medical records and current medical literature occupational therapy 
services provided from 2/22/23 through 2/28/24 were and are medically necessary for treatment 
of this patient. The use of occupational therapy services will help address the patients ADLs, 
sensory  integration,  and  coordination,  as  well  as  gross  and  fine  motor  skills.  Continued 
occupational therapy services can help establish new performance baselines for this patient while 
the developing central nervous system still has neuroplasticity. In this case, the patient started 
occupational therapy for the habilitative treatment of deficiencies associated with an autism 
spectrum disorder. Specifically, the patient has motor coordination problems and deficits in ADLs, 
which are planned to be addressed with the requested occupational therapy. Occupational therapy 
is the most appropriate treatment modality to address the patients deficits (Campi, et al.). Given 
these findings, the occupational therapy (CPT codes 99214, 97530, 97535, 97166, and 97112) 
from 2/22/23 through 2/28/24 was and is medically necessary for the treatment of this patient.