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

An enrollee has requested authorization and coverage for full body Magnetic Resonance Imaging.The submitted documentation does not support that the requested services are medically necessary. The patient has had multiple chronic complaints since he sustained an industrial injury and was also reportedly exposed to some chemicals in the workplace before that as well. The patient has had symptoms that have persisted, and he has undergone various evaluations and tests that have included spine MRIs, spine surgery evaluation, pain management evaluation, gastrointestinal evaluation, esophagoduodenoscopy, and colonoscopy. There are no documented indications that any of the health care providers he has seen have recommended this test. In this case, there is no specific clinical indication for the proposed full body MRI in the records received for review. There is no documented differential diagnosis or treatment decision-making that requires the proposed testing. The rationale for the proposed test would appear to be a screening test. This test, however, is not appropriate as a screening test, outside of potential applications in oncological management. At this time, there are no indications that the requested full body MRI would result in any changes in clinical management or improvements in outcomes. There is also a potential that this testing would result in false positive findings that would result in further testing and interventions, including invasive interventions that are unnecessary. Under these circumstances, the requested full body MRI is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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

A 39-year-old female enrollee has requested for duodenal switch bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the guidelines for weight loss surgery set by the National Institutes of Health. The long-term outcome of weight loss surgical procedures is well-documented. The duodenal switch bariatric surgical procedure has a superior long-term success rate as compared to other weight loss surgical procedures.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) (CPT code 47382). The patient has oligometastatic breast cancer with persistent right upper quadrant pain due to her liver lesion. Pain alleviation is an acceptable standard of care goal for cancer care. Focal therapy is likely to be effective, without the risk of complications or side effects from systemic therapies. There are multiple accepted modalities for focal treatment of tumor to provide symptom management. Radiofrequency ablation (RFA) is an effective palliative local therapy that can achieve symptom management due to progressive disease (Kwapisz). Additionally, there is data to support improved disease control and long-term survival with RFA of oligometastatic breast cancer (Kwapisz). Given these findings, the requested RFA (CPT code 47382) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested RFA (CPT code 47382) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in medical oncology 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

The parent of a 16-year-old male enrollee requested 15 hours per week of direct applied behavioral analysis (ABA) and 4 hours per month of ABA supervision for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Two physician reviewers found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Granpeesheh, et al; Kelley, et al).  While this patient has made significant gains in behavior with ABA services, he continues to present with specific maladaptive traits that need to be addressed.  Moreover, the services provided in the school through the patients IEP are unrelated to the services needed per his behavioral health treatment plan.  All told, the requested 15 hours per week of direct ABA and 4 hours per month of supervision are medically necessary for treatment of the patients autism spectrum disorder.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that TMS is a specific treatment for severe depression and is U.S. Food and Drug Administration (FDA) approved. The patient has been treated with psychopharmacology and psychotherapy, and he has received adequate trials in terms of dosage and duration of treatment with two FDA approved selective serotonin reuptake inhibitors (SSRI) mediations, Prozac and Lexapro, as well as Wellbutrin and Pristiq, which have different mechanisms. He has also been augmented with stimulants, atypical antipsychotics, mood stabilizers and a folate analogue, all without benefit. He has been engaged in CBT psychotherapy weekly for more than six months. In this case, the patient has been treated with the standard of care treatments for depression without much improvement. In sum, the patient has treatment resistant depression and treatment with TMS is clinically indicated. For the reasons provided, the request for TMS has been established as medically necessary for treatment of the patients major depressive disorder. 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 physician 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 45-year-old man who underwent ACL reconstruction. Postoperatively the patient utilized a continuous passive motion (CPM) machine. The Health Plan has denied reimbursement for utilization of the CPM machine on the basis it was not medically necessary for treatment of the patients condition.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested for cardiac-gaited cerebral spinal fluid (CSF) flow study performed via magnetic resonance angiography (MRA) and magnetic resonance imaging (MRI) of the brain, cervical spine and lumbar spine for evaluation of the enrollees Chiari 1 malformation.  Findings:  The physician reviewer found that the scientific data comparing the CSF flow patterns in patients who are symptomatic for Chiari 1 malformation with those who are asymptomatic for tonsilar ectopia, is extremely limited. Hofkes and colleagues studied 17 patients with tonsils extending more than 5 mm below the foramen magnum and classified patients as symptomatic for Chiari 1 malformation or asymptomatic for tonsilar ectopia. The CSF flow images of the two groups were read independently in blinded fashion by four neuroradiologists. Of 17 patients, 9 were classified by the neurosurgeon as symptomatic Chiari 1 malformation and 8 as asymptomatic tonsilar ectopia. While the readers detected an abnormal CSF flow pattern significantly more often in patients with symptomatic Chiari 1 malformation than in patients with asymptomatic tonsilar ectopia, the utility of the test is questionable given the low sensitivity and specificity. In addition, the authors cautioned that the non-quantitative nature of the test also limits its current utility.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested  for speech therapy and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that in reviewing the speech therapy report provided by the non-plan speech therapist, the program goals are functional in nature and are not solely within the purview of educational therapies. I therefore find them medical in nature. The in-plan speech and language evaluation included no standardized testing and limited the evaluation only to physical function of speech without taking into account the pragmatic nature of speech. There need not be impairment in physical function in order for speech and language therapy to be considered medically necessary. California Assembly Bill (AB) 88 lists autism spectrum disorder as a diagnosis that must be treated in parity with other medical conditions. The submitted documentation confirms the patients diagnosis of autism. Furthermore, the above-cited literature demonstrates that speech and language therapy is well-accepted as standard treatment for patients with autism and can provide benefit in terms of language and function. Accordingly, I find the requested speech and language therapy twice per week is medically necessary.Regarding occupational therapy, the in-plan evaluation included no standardized testing. The only comment regarding activities of daily living was observation of the patients ability to put on/take off her coat and shoes. The therapist noted that these required setup. The non-plan occupational therapist utilized standardized testing including the Hawaii Early Learning Profile and the Sensory Profile. These tests revealed significant deficits in praxis and sensory processing associated with the patients autism. This therapist proposed goals that are functional in nature including traversing steps and throwing a ball. Occupational therapy is a well accepted modality for patients with autism. There is evidence supporting the use of occupational therapy to improve deficits of neurologic processing and sensory information. Based on this patients documented deficits, she is an appropriate candidate for occupational therapy. As such, 10 hours per month of occupational therapy is medically necessary for the patient.For the reasons set forth above, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested partial right knee replacement (Uni Knee Arthroplasty) for medical treatment of her osteoarthrosis.  Findings:  The physician reviewer found the current medical evidence supports the requested partial right knee replacement in this clinical setting.  MRI documented mild to moderate tricompartmental osteoarthritis with patella osteophytes. The arthroscopic surgical inspection of the joint through direct visualization documented Outerbridge grade 3 and 4 changes of the medial compartment and Outerbridge grade 2 changes of the distal patella surface.  The arthroscopic findings under direct visualization and probing provide the highest levels of objective documentation.  The requested services are likely to be of benefit in this patients case.  All told, the requested partial right knee replacement (Uni Knee Arthroplasty) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Synvisc-One injection. Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. However, there is insufficient evidence for other conditions including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. Clinical examination was consistent with imaging evidence of mild tricompartmental cartilage irregularity and the diagnosis of patellofemoral pain syndrome. X-rays did not evidence right knee osteoarthritis. Functional difficulty was documented with prolonged walking or hiking, prolonged sitting, and mowing the lawn. Conservative treatment had included activity modification, physical therapy, home exercise, and anti-inflammatory medications with slow improvement. Current evidence based medical guidelines and peer-reviewed literature do not support the use of Synvisc-One injections for patellofemoral pain syndrome or in the absence of knee osteoarthritis. 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 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 23-year-old female enrollee has requested continued residential treatment center care. Findings: The physician reviewer found that this patient is not showing any signs of her binging or purging behaviors. Her current treatment plan shows this patient to be steadily progressing, with appropriate weight gain. It does not appear that this patient requires the restrictive setting of a residential treatment care (RTC) facility. The literature documents conflicting reports as to the efficacy of treatment of anorexia nervosa in a patient such as this who currently is undergoing a steady gain in weight. It appears that she could be treated in a lesser restricted environment, such as the outpatient setting. This patient had previously been treated at this same RTC with good results having been achieved upon her discharge. The skills that she had gained from that previous admission, and the ability to continue advancement in her weight without intense interventions demonstrates that this patient no longer required this level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested intravenous immunoglobulin (IVIG) infusions for the treatment of her elevated natural killer cells during pregnancy. Findings:  Three physician reviewers found that IVIG therapy for recurrent pregnancy loss is not an accepted therapy. There is much more data to support anticoagulant therapy for thrombophilia related losses (which is the case with this patient) or immunosuppression in patients with overt autoimmune disease. Neither testing for natural killer activity nor treating increased activity with IVIG therapy has been proven to be effective.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested  authorization and coverage for a 28-day residential treatment center (RTC) program with the following CPT codes: 97112 x 96, 97116 x 96, 97530 x 96, 97535 x 96, 90837 x 15, 90846 x 4, 90847 x 4, 96151 x 12, 96154 x 12, 97810 x 8, and 97811 x 8. Findings:  The physician reviewer found that a review of pediatric complex regional pain syndrome (CRPS), Weissmann and Uziel report, Exercise and physical therapy (PT) are the main treatment cornerstones of all pediatric CRPS patients. The authors further note regarding studies of pediatric patients with CRPS, Brooke and Janselewitz reported complete resolution of pain in 25 of 32 children with CRPS after intensive inpatient rehabilitation, which consisted of physical, occupational, and psychological therapy, with no other medical intervention, followed by a home program. A study of a day hospital pediatric pain rehabilitation program performed by Logan et al. included 56 pediatric CRPS patients who failed to improve with outpatient treatment. Treatment included daily physical, occupational and psychological therapy, for a median duration of three weeks. They found statistically significant improvements from admission to discharge in pain intensity, functional disability, subjective reports of limb function and occupational performance, these functional gains were maintained or further improved at follow-up. Hoffart and Wallace report that the standard treatment for pediatric patients with amplified pain syndromes is multidisciplinary, emphasizing exercise therapy, cognitive-behavioral treatment, and self-regulation. In this case, the patient has a diagnosis of localized amplified musculoskeletal pain syndrome. She has tried and failed medication management with multiple different classes of drugs, outpatient physical therapy, and behavioral pain management. The patients provider has recommended admission to a pediatric amplified pain rehabilitation (PAPR) program. In this clinical setting, given the patients severity of disease and failure to respond to treatment, the requested services are medically indicated. Therefore, a 28-day RTC program with the following CPT codes: 97112 x 96, 97116 x 96, 97530 x 96, 97535 x 96, 90837 x 15, 90846 x 4, 90847 x 4, 96151 x 12, 96154 x 12, 97810 x 8, and 97811 x 8, 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 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 authorization and coverage for speech therapy and occupational therapy services. Findings:  The physician reviewer found that In the most recent Practice Guidelines from the American Academy of Pediatrics on the treatment of children and adolescents with autism spectrum disorder (ASD), Hyman and colleagues state, `Speech-language therapy is the most commonly identified intervention provided for children with ASD. The authors also describe, Almost two-thirds of preschool-aged children with ASD are reported to receive occupational therapy services. However, adolescents with autism spectrum disorders have a high rate of irritability and aggressive symptoms. Matson and colleagues indicate, Severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and behavioral interventions can significantly reduce such behaviors. Given the increased physical size of older children and longer history of these problems, treating these behaviors effectively is important. Matson and colleagues conclude, Psychological methods, particularly ABA therapy, and pharmacotherapy have been the most frequently addressed treatments for challenging behaviors associated with autism spectrum disorder in the research literature. In this case, it is documented on multiple occasions in the medical record that the patients aggressive behavior poses significant risk of injury to speech and occupational therapists attempting to provide treatment, even if a behavioral therapist is present. Even with a behavioral technician present, there remains a risk of the patient injuring a therapist. Moreover, the provider notes, Current behavioral therapists are not helping because they are afraid he will become aggressive. The patients current behavior precludes the safe provision of in-person behavior. Therefore, speech therapy and occupational therapy are not medically necessary for treatment of the patient, either in-home or in a clinic setting with a behavioral therapist present. Additionally, the requested services are not within the generally accepted standards of mental health and substance use disorder care. Also, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration.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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male has requested coverage for past residential treatment services provided for treatment of his major depressive disorder, attention deficit/hyperactivity disorder, combined type, and anxiety disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  The American Psychiatric Association supports residential treatment in instances where less restrictive treatment settings have failed.  The submitted medical documentation notes that the patient displayed anger related to his deafness and reluctance to embrace his mixed ethnicity.  Conflicts such as these strike the core of identity and can undermine the second individuation process.  Patients who fail to successfully negotiate this stage of development often present with mood and anxiety symptoms secondary to poor sense of self and self-defeating coping skills.  This patient was not particularly motivated for care.  He had been unable to consistently manage his frustrations in the residential setting.  A 24-hour supervised setting with the benefits of a comprehensive treatment was indicated for the time frame under review.