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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. While the patient does not meet the criteria for autism, his medical condition meets the criteria for treatment with ABA. The current medical literature suggests that ABA is an effective treatment for patients with ADHD, intellectual disability, and aggressive behavior disorder. Colleagues conducted a meta-analysis on the effect of behavioral treatment on patients with ADHD. Treatments included parent based, teacher based, and child based strategies utilizing operant contingencies and antecedent manipulation. The authors found that behavioral treatments improve the functioning of children with ADHD. In addition, colleagues described the outcomes of 52 patients who underwent behavioral assessment and treatment in the outpatient setting. Of the patients evaluated, 35 had an intellectual disability, and nine were diagnosed with ADHD. The authors reported that in their study, behavior intervention yielded a 96% reduction in problem behavior compared to baseline. Considering this patients history of ADHD, intellectual disability and aggressive behavior disorder, his behavioral issues are likely to improve with ABA therapy. As the patients records do not include a current evaluation for behavioral consultation services, a thorough evaluation is indicated to assist in determining the frequency of ABA therapy that is appropriate. All told, the requested ABA therapy is medically necessary for treatment of this patients medical condition. 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 psychology and is a board certified behavior analyst 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:   An enrollee has requested for physical therapy for treatment of her diastasis recti.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  Diastasis recti abdominis is common following pregnancy.  Antenatal and postnatal exercises, including in the formal physical therapy setting, are commonly recommended.  However, there is a dearth of high-quality published research to inform the medical literature.  A recent meta-analysis by Benjamin and colleagues noted that the literature was of poor quality and concluded that nonspecific exercise may or may not help to prevent or reduce [diastasis recti abdominis] during the ante- and postnatal periods.  There is a lack of high-grade evidence that formal physical therapy improves the clinical course or outcomes for this condition.  All told, the requested physical therapy is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested therapy 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 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

A 62-year-old female enrollee has requested the Flexitouch Lymphedema System for the treatment of her lymphedema. Findings:  Three physician reviewers found that this patient has impairment of her activities of daily living despite having tried all other available standard therapies and still suffers from lymphedema and bouts of cellulitis. The patient has complied with the recommended standard treatments. Given that the patient has exhausted all standard modalities, use of the Flexitouch System is medically reasonable and appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The guardian of an enrollee has requested computed tomography (CT) scan of the abdomen for evaluation of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. In this case, the patients symptoms are primarily functional, but with some contribution from gastroesophageal reflux, explaining the improvement that was described at the appointment while on high dose proton pump inhibitors. The degree of disability that the patient is experiencing, with numerous school absences, does not indicate an anatomic or inflammatory problem. Rather, as described by Assa and colleagues, functional pain can be just as disabling as organic conditions such as inflammatory bowel disease. Dhroove and colleagues reported on the low utility of testing in children with functional abdominal pain, including the use of abdominal ultrasound and abdominal CT. Given the above, the requested services are not indicated for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics and pediatric gastroenterology 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 37-year-old female enrollee has requested combined individual psychotherapy and medication management at a frequency of once per week for treatment of her dysthymic disorder and binge eating behaviors.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with symptoms of a behavioral health condition, which impairs her psychosocial functioning, and requires pharmacological treatment. Weekly psychotherapy with medication management is appropriate to treat the patients condition and is consistent with standards of good medical practice. The records indicate the patients ability to function was impaired with only twice monthly session. Further, weekly psychotherapy has been shown to be more beneficial for treatment of the patients medical condition and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage and continuation of skilled nursing facility services for treatment of the enrollee, who had a below the knee amputation performed to the right leg. Findings: The physician reviewer found that the patient underwent a transtibial (below knee) amputation, and has a history of a contralateral transtibial amputation. Her functional status upon transfer to a skilled nursing facility was below her baseline. Initiation of inpatient rehabilitation was appropriate, with a goal of improving her functional status towards independence and healing her residual limb wound (Esquenazi; Goldberg; Klarich and Brueckner). The patient has had a dehiscence at the lateral margin of the surgical closure site in the right residual lower limb that has been slow to heal. The wound was granulating. It had stabilized sufficiently for the patient to have been transitioned off of intravenous antibiotics.  However, there was a local trauma, and the wound had enlarged in size. There was enlargement of the sinus tract, which was now questionably exposing bone. While x-rays did not reveal evidence of recurrent osteomyelitis, additional inpatient care for another week, for close medical and nursing evaluation, is clinically appropriate. Moreover, an additional week was necessary to confirm overall wound stability and to minimize risk of worsening wound status and need for further surgery, such as revision amputation, including a more proximal level amputation. In addition, the patient was making some modest functional progress with respect to her transfers and self-care. One additional week to work on transfers and self-care in conjunction with her wound care was and is medically indicated. Therefore, the continuation of skilled nursing facility services prior to wound stability was medically necessary for treatment of this patient. However, continuation of skilled nursing facility services post wound stability being achieved was and is not medically necessary.Final Result: The reviewer determined that a portion of the services at issue was 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback therapy. The submitted documentation supports the medical necessity of the requested services. The records document fecal incontinence unresponsive to conservative therapy including medications and pelvic floor exercise. The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Treatment of Fecal Incontinence states that biofeedback should be considered as an initial treatment for patients with incontinence and some preserved voluntary sphincter contraction. The American College of Gastroenterology guideline for the management of benign anorectal disorders states that pelvic floor rehabilitative techniques such as biofeedback are effective and superior to pelvic floor exercises alone in patients with fecal incontinence who do not respond to conservative measures. The medical literature supports the use of biofeedback as an effective therapy for fecal incontinence. Therefore, the requested biofeedback therapy 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 internal medicine with sub-specialty certification in gastroenterology 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 63-year-old female enrollee requested authorization and coverage of portable oxygen for the treatment of chronic obstructive pulmonary disease.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested reimbursement and continued authorization and coverage for residential treatment facility level of care services provided from a spefici date to the present and ongoing for treatment of the enrollees bulimia nervosa, major depressive disorder and anxiety disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. It is impossible for even the most comprehensive of standard placement algorithms to account for the myriad of variables unique to complex cases.  Accordingly, we entrust physicians and therapists working directly with the patient population to interpret and apply clinical guidelines and patient placement criteria in consideration of clinical presentation and treatment needs.  This current concept of care is accurately captured in the American Psychiatry Association (APA) Clinical Practice Guideline: In determining a patient's initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge; patients who reach a healthy body weight but are discharged before this learning occurs are likely to immediately decrease their caloric intake to excessively low levels that are often insufficient to sustain their healthy body weight.This patient, with a long mental health history including suicide attempts, has neither integrated the sustained learned behaviors nor consolidated the treatment gains necessary to succeed in the outpatient setting.  She requires the structure and 24 hour supervision afforded by residential placement to cement the therapeutic skills necessary for success.  Further, her persistent symptomatologies, negative schemas, self-defeating behaviors, unrefined copings strategies including suicidal ideation as a punishment for her failure to progress, and pathological distortionism would more than likely undermine efforts at a lower level of care at this time, thus creating a risk for acute psychiatric admission.  Accordingly, the eating disorder residential treatment center services provided from the date in question and forward were and are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee genetic testing (Foundation One) for medical evaluation of her lung cancer.  Findings:  Two physician reviewers found that according to the NCCN guidelines, the Panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. In this case, it was under these circumstances that the Foundation One assay was ordered, and as such, its use was consistent with current standards of care and was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for applied behavior analysis (ABA) services of 60 hours per week at 2:1 ratio, 10 hours per month of mid-level supervision, and 120 hours per month of high-level supervision, in the alternative ABA services of 60 hours per week at a 2:1 ratio, 38 hours per month of mid-level supervision, and 12 hours per month of high-level supervision. The Behavior Analyst Certification Board (BACB) outlines that, many variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment help determine which model is most appropriate. A targeted assessment and treatment in a center-based model, by providers specifically trained to treat challenging behavior, is preferable to in-home ABA services. The BACB noted that autistic patients demonstrating severe destructive behavior disorders might require treatment in more intensive settings, such as specialized intensive-outpatient, day- treatment, residential, or inpatient programs. The patients caregiver reports that the 60 hours per week of 2:1 ABA therapy is appropriate. However, the patient and caregiver have not made progress with this intensity, challenging behaviors have increased, and multiple discharges have ensued. Overall, the records do not demonstrate that the home is an optimal treatment setting, as it has exacerbated the patients symptoms. All told, the requested ABA services of 60 hours per week at 2:1 ratio, 10 hours per month of mid-level supervision, and 120 hours per month of high-level supervision, in the alternative ABA services of 60 hours per week at a 2:1 ratio, 38 hours per month of mid-level supervision, and 12 hours per month of high-level supervision are not medically necessary for 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 a licensed B.C.B.A, board certified in psychology, 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 61-year-old male enrollee has requested the removal of his benign skin lesions for treatment of his seborrheic keratoses. Findings:  The physician reviewer found that this case involves a request for liquid nitrogen destruction of seborrheic keratoses.  Destruction of these lesions is considered cosmetic except in instances of inflammation, bleeding, or pain associated with traumatization of the lesions (Brodsky, et al.).  The seborrheic keratoses described in the patients medical records are not documented to be inflamed, bleeding or painful. The additional information provided documents a history of non-melanoma skin cancer, which can place patients at increased risk of developing additional cancerous lesions. This would support annual examinations of the skin by a dermatologist.  However, the presence of seborrheic keratoses does not contribute to an increased risk of skin cancer or potential for malignant conversion. Further, the presence of seborrheic keratoses does not place the patient at risk of infection.  If a lesion were to become inflamed due to trauma, then treatment would be considered medically necessary. However, it is not necessary to prophylactically treat seborrheic keratoses to reduce the risk they will become inflamed or infected, as the vast majority of lesions do not.  As such, the treatment of non-inflamed seborrheic keratoses is not considered to be medically necessary and the Health Plans denial of the patients request for treatment of these lesions should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested lumbar spinal fusion (63048 x 1, 22612, 22840, 22630 and 22851) for treatment of her degenerative spondylolisthesis at L4-5.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Lumbar fusion is supported for patients with symptomatic lumbar spinal stenosis when stenosis is moderate to severe, there is clinically significant functional impairment despite at least three months of conservative medical therapy, and there is lumbar spondylolisthesis for spinal instability on imaging, or spinal instability is anticipated with surgery.  In this case, the MRI of the lumbar spine demonstrated mild central stenosis with some left lateral recess stenosis at L4-5, with moderate narrowing of the left neural foramen. It was noted that the patient had attempted Neurontin and epidural steroid injections with no pain relief. However, there was no documentation of instability on diagnostic imaging.  In addition, there was no discussion of the need for wide decompression that would result in temporary intraoperative instability. Based on the clinical documentation provided, lumbar spinal fusion (63048 x 1, 22612, 22840, 22630 and 22851) is not medically necessary for treatment of 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 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.