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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program services from the date of service in question, forward. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the records, it appears that she has stabilized.  Her medical status is intact, and she appears psychiatrically stable.  She is at her ideal body weight.  She continues to have issues with extended mealtimes as well as requirements for prompting to finish meals.  The records do not demonstrate that she needs continued partial hospitalization program care.  Per the clinical notes, she could now be treated safely and effectively in an intensive outpatient program.  She had some minor laboratory abnormalities which were not serious in nature and could be addressed on an outpatient basis.  The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of anorexia nervosa.  All told, partial hospitalization program services from the date of service in question, forward were not and are not medically indicated for the 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 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: Overturned

The patient is a 54-year-old male with a diagnosis of ulnar neuropathy who had failed to respond to anti-inflammatory medications, physical therapy and time. Chiropractic care ensued and relief was slow but, nonetheless, reported by the patient. The Health Plan has denied coverage for the chiropractic therapy the patient received on the basis it was not medically necessary for treatment of the patients medical condition.As this patient failed to improve with a course of anti-inflammatory medication and a course of physical therapy, chiropractic care was medically reasonable and indicated. Chiropractic care is an appropriate treatment modality for a diagnosis of ulnar neuropathy. Furthermore, the submitted documentation demonstrates the patient experienced gradual improvement with chiropractic treatment. As such, I have determined that the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

The family of a four-year-old female enrollee has requested speech therapy (Tomatis technique) for the treatment of the enrollees autism and speech-language disorder. Findings:  Three physician reviewers found that this autistic child also has a history of recurrent otitis media and a chronic auditory problem. Both problems are recognized as benefiting from speech therapy. This patient received therapy through the Tomatis technique. The Health Plan considers the Tomatis technique investigational and has denied reimbursement for the therapy at issue. There is no definitive proof that the Tomatis technique method is more effective than standard speech treatment. The Tomatis technique is more than 40 years old, and there are no controlled studies demonstrating its effectiveness. In contrast, standard speech therapy is known to be beneficial for treatment of patients with autism.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested right anterior total hip replacement surgery for treatment of her medical condition.   Findings: The physician reviewer found that the submitted documentation supports the requested services in this patients case.  Sciatic nerve injury is a greater risk in the posterior approach.  The anterior approach has been associated with earlier functional recovery and shorter stays in the hospital attributed to the muscle sparing properties of the anterior approach.  There is sufficient support for the requested services in this clinical setting.  All told, the requested right anterior total hip replacement surgery is medically indicated 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

A 32-year-old female enrollee has requested removal of left kidneyfor treatment of her history of hydronephrosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The medical records do not support the requested services in this clinical setting.  Nephrectomy is not likely to relieve this patients abdominal pain, bloating, nausea and diarrhea.  She had no relief with prior stent placement and pyeloplasty.  The left kidney appears to have normal function and is not obstructed.  The clinical notes are consistent with a type of chronic pain syndrome, and nephrectomy is not likely to provide benefit.  All told, removal of left kidney is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for balloon sinuplasty. The enrollee has chronic sinusitis. She reports three to four sinus infections per year that do not completely resolve; despite treatment with antibiotics. She underwent surgery, but the procedure did not improve her symptoms of sinus pressure, aural fullness, nasal congestion, and post nasal drip. A computed tomography of the sinuses showed moderate to severe pansinus disease. Balloon is the endoscopic use of a balloon device to enlarge or open the outflow tracts of sinuses; as a stand-alone procedure or with endoscopic surgery.  However, because endoscopic sinus surgery does not directly treat the underlying inflammatory disorder, sinus surgery must be followed by medical management to control the inflammatory processes or symptoms will invariably return. The medical records are insufficient to show medical management has not been successful for this enrollee. The records indicate the enrollee has had a positive allergy test that included multiple allergens, but the records did not show evidence her allergies had been treated.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in otolaryngology 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

The parent of a 17-year-old male enrollee has requested residential treatment provided for the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Residential treatment was recommended by community providers who best knew the patient and his family system, which represents a critical factor in the placement determination process. The patients concerning substance dependence, psychiatric issues and home environment were not conducive to a less restrictive setting and a four-day stay at residential was not long enough to make meaningful treatment gains. Considering the patients anxiety burden, learned behaviors and psychosocial-cultural stressors, a prompt return to the family system would have resulted in undue morbidity and an unnecessarily elevated risk of relapse and need for a higher-level of care. In sum, placement at the residential setting was the most appropriate disposition and the one that offered the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains and ultimately fostering harmonious autonomy. Considering the clinical presentation, patient and family histories, and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment at the residential level of care from the time frame specified was safe, appropriate and medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 25-year-old male enrollee has requested for emergency services for treatment of her eye pain.  Findings:  The physician reviewer found that the patients pain as a 10 on a scale of 1 to 10. Although his symptoms had been present for 4 days, they had progressed over the past day. His vision was slightly decreased and blurry. Infectious complications of contract lens use range from bacterial conjunctivitis to keratoconjunctivitis to corneal ulcer. Pseudomonas accounts for 75% of corneal ulcers related to contact lens use and causes permanent visual loss. Although this patient was diagnosed with conjunctivitis, his symptoms were worrisome for a corneal ulcer. Any delay in differentiating among these contact lens related infections and antibiotic treatment could cause permanent visual impairment. Based upon this information it is reasonable that a prudent layperson would believe lack of immediate medical attention could result in serious impairment or dysfunction of his bodily functions if he experienced severe eye pain associated with diminished visual acuity.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male with over a 20-year history of substance abuse of Vicodin and alcohol. He has had two prior instances of inpatient treatment, both resulted in relapses. The patient also apparently suffered from depression and post traumatic stress disorder (PTSD).  He stated his life was out of control related to his depression and significant abuse of multiple substances. On 2/21/04 the patient was admitted to an inpatient treatment program. He was discharged  in March 2004. A request has been made for reimbursement for the inpatient rehabilitation services the patient received.Review of the submitted clinical records indicates the patient was not acutely suicidal, or psychotic during the inpatient admission at issue. The records demonstrate the patient was medically stable. Although he had a long history of polysubstance abuse with symptoms of depression, there is no evidence he required inpatient treatment. The patient could have been appropriately treated at an outpatient level of care in a chemical dependency program by a psychiatrist. Therefore, I have determined the services at issue were 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 17-year-old female enrollee has requested reimbursement for intensive outpatient mental health services for treatment of the enrollees depression. Findings:  The physician reviewer found that current standards of psychiatric practice recommend that patients be placed in the least restrictive treatment setting that is likely to be safe and effective. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, some adolescent patients with psychiatric conditions require treatment at a more intensive level of care. The American Academy of Child and Adolescent Psychiatrys practice parameters for the treatment of depression state, the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care. The decision for that level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment. Ultimately, the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested Lp-PLA2 testing for an evaluation of her hyperlipidemia. Findings:  Three physician reviewers found that the literature indicates that the predictability of Lp-PLA2 testing is no longer statistically significant after adjustment for other risk factors. There is insufficient evidence that Lp-PLA2 testing is useful in evaluating stroke risk. To date, it would be considered complementary to traditional risk factor stratification for identifying individuals at increased risk for stroke. The consensus is that there is lack of evidence from prospective clinical studies that incorporation of Lp-PLA2 testing in cardiovascular risk assessment improves clinical outcomes. Adult Treatment Panel III guidelines do not include a recommendation for Lp-PLA2 testing in assessment of coronary artery disease risk. The benefit of this testing has not been scientifically established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested ambulatory event monitoring with real time analysis for the treatment of her medical condition. Findings:  Three physician reviewers found that ambulatory event monitors with real-time analysis have been approved for general use in the United States by the Food and Drug Administration. The published research demonstrates that it is superior to standard telemetry devices, particularly in the diagnosis of rhythm abnormalities that may be asymptomatic at the time of occurrence. Because the presence of atrial fibrillation may require systemic anti-coagulation even in the absence of symptoms, the device used was preferable to other home telemetry systems. Since the use of a real-time ambulatory event monitor could affect patient management, its use in this setting was medically justified and consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for mental health treatment partial hospital program level of care. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The documentation indicates a moderate risk of harm. The patient has a history of an aborted suicide attempt. With regards to functional status, the records support a score of 3. The patient has moderate functional impairment. He stopped attending school due to worsening anxiety and depression. In terms of comorbidity, the records support a score of 3. The patient has significant comorbidity. The records document major depressive disorder and unspecified anxiety disorder. The patient had a referral to be tested for autism and attention deficit/hyperactivity disorder. With regards to environmental stress, the records support a score of 2. The patient had a mildly stressful environment. The patient has supportive parents and lives in a supportive environment. There are some expectations for performance at school, which the patient has not been able to meet. In terms of environmental support, the records support a score of 2. The patients parents are supportive of the patient. With regards to resiliency, the records support a score of 3. The patient has had an equivocal resiliency and response to treatment. He has had prior outpatient treatment with a psychiatrist and outpatient therapy which did not resolve the patients symptoms of anxiety and depression. With regards to acceptance and engagement, the records support a score of 2. The patient is cooperative with treatment. He had made modest improvement in his anxiety and depression. Therefore, the records support a composite score of 18. Based on these criteria, the patient meets criteria for intensive outpatient program level of care. The patient continued to need treatment for his unspecified anxiety disorder and major depressive disorder, but this could be performed in a less restrictive environment. Therefore, the requested mental health treatment partial hospital program level of care is 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 board certified in psychiatry with expertise 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: Overturned

The patient is a 42-year-old female with a documented history of right temporomandibular joint pain and dysfunction. It appears the problem started after a motor vehicle accident in 1987 in which she sustained severe head injuries and the loss of some teeth. The maxilla is edentulous as is the posterior mandible bilaterally. The patient wears a full upper denture prosthesis and partial lower denture prosthesis. There is documented degenerative disease in the right temporomandibular joint, atrophy of the maxillary and mandibular alveolar ridges, and poor stability of her denture prostheses.  The patient has undergone bone grafting and placement of dental implants and has requested reimbursement for these services. The Health Plan has denied the patients request on the basis that the services at issue were not medically necessary.The services at issue constitute treatment for a condition affecting both the upper and lower jawbones as well as the right temporomandibular joint. Treatment with augmentation bone grafting, placement of endosseous dental implants and fabrication of new prostheses was necessary to restore function and relieve pain. The patients existing denture prostheses were inadequate to provide stable dental occlusion and temporomandibular joint pain and dysfunction were exacerbated by this unstable dental occlusion. Therefore, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee requested 30 sessions of chiropractor care for medical treatment of his degenerative disc disease.   Findings:  The physician reviewer found that this patient reports that his ability to perform activities of daily living are affected due to his pain and worsening condition, and that chiropractic treatment has helped his condition.  However, documentation of subjective and objective pain as well as clinical assessment and evaluation is needed to support an indication for continued chiropractic care. This patients records do not support the medical necessity of the requested chiropractic treatment absent this information.  Thus, the requested 30 sessions of chiropractic care are not medically necessary for treatment of this patients chronic back pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar fusion of the L4-5 and L5-S1. Findings:  The physician reviewer found that prospective methodology with a broad definition of complications, Campbell and colleagues reported a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, the authors noted a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery. In an analysis of perioperative morbidity and mortality after anterior, posterior, and anterior/posterior spine fusion surgery, Memtsoudis and colleagues concluded that, despite being performed in generally younger and healthier patients, anterior/posterior spine fusion and primary anterior spine fusion were associated with increased morbidity and mortality. The authors noted that these findings could be used for the purposes of risk stratification, accurate patient consultation, and hypothesis formation for future research. In this case, the patient has chronic lumbar pain with intermittent lumbar radiculopathy and is being treated for multi disc degeneration. He reports persistent pain and is unable to sit for more than ten minutes at a time despite continued conservative care. On examination, he had altered sensation in the anterior shin and the left dorsal foot. Magnetic resonance imaging (MRI) of the lumbar spine revealed disc degeneration at L3-4 and L5-S1 with annular tears L3-4 and L4-5 and dark discs at L3-4-5-1. However, dynamic flexion-extension x-rays and MRI imaging did not show instability and/or a reference to impending intraoperative instability. In this clinical setting, the requested service is not medically indicated. Therefore, lumbar fusion of the L4-5 and L5-S1 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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.