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

The parent of a five-year-old male enrollee has requested for occupational therapy (sensory integration therapy) for treatment of the enrollees developmental coordination disorder. Findings:  Two physician reviewers found that the requested therapy has the potential to ameliorate pre-existing damage to the developing brain.  While most underlying etiologies that give rise to developmental delay are due to a static insult to the central nervous system, they must be viewed as superimposed on the continuum of the developing nervous system, which still has considerable plasticity to respond to insults.  Thus, the notion that occupational therapy has no indication for a chronic condition such as developmental delay is incorrect, since therapy, like other sensorimotor training, can condition and change the developing nervous system, taking advantage of brain plasticity.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee, who had a cerclage placed for cervical incompetence, has requested authorization for obstetrical services.Findings:  The physician reviewer found that this patient presumably had cervical incompetence. However, in the absence of evidence of any other pregnancy complications, the BPP, fetal doppler velocimetry ratios and expanded office visit were not medically necessary. The fetal growth was documented as normal with appropriate interval growth.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested lumbar artificial disc replacement (at the L4-5 level) and lumbar fusion (at the L5-S1 level) for treatment of his low back pain. Findings:  Three physician reviewers found that artificial disc replacement has been the subject of much debate. Despite encouraging early results, there is still a need for results regarding the long-term outcome of these implants, and whether their use results in improved outcomes (Mirovsky and colleagues). This motion-sparing technology has not yet demonstrated efficacy with data (Madigan and colleagues). Further long-term study is necessary (Resnick and Waters) in order to confirm the benefits of artificial disc replacement as compared to standard alternatives. The role of fusion in the treatment of degenerative disease in the lumbar spine also remains a source of controversy. There is some evidence to support the use of fusion in cases with demonstrated instability, but further trials are needed to clarify the situation (Gibson and Waddell). The use of wide decompression or facetectomy may result in iatrogenic instability and thus may call for fusion (Resnick and colleagues). Trauma, tumor, infection, and spondylolisthesis may require fusion, but it is rarely indicated for routine discectomy or abnormal radiography without appropriate clinical findings. In summary, since there is no documentation of instability or other indication for fusion, the necessity for that procedure is not evident, and therefore the denial was appropriate. Further, since questions as to the efficacy of artificial disc replacement remain, the procedure is appropriately considered to be investigational and/or experimental in nature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential mental health treatment services for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that after a detailed and intensive review, the patient does not meet the medical necessity criteria for admission and continued care at the residential treatment facility level of care. The patient has not previously been treated in a less restrictive level of care, is not psychotic, and the patient is able to take care of himself. Thus, although the patient does need mental health services, treatment at the residential level is not medically necessary. The multidisciplinary intensive outpatient program (IOP) level treatment is less restrictive and is likely to be more efficient and effective. For these reasons, the residential mental health treatment services provided were not and are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewers 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 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

SummaryThe patient is a 54 year old male who has prolonged acute hospitalization who was subsequently admitted to a skilled nursing facility for physical therapy (PT), occupational therapy (OT), IV antibiotics and wound care.  The patient request reimbursement of the services provided after October 2006.  The Health plan denied his request based upon a determination that the services provided after October 2006 were not medically necessary.  The reviewing physician decided that the Health Plan denial should be upheld.Analysis and FindingsClinical Facts:  The patient has a prolonged acute hospitalization who was subsequently admitted to a skilled nursing facility for physical therapy (PT), occupational therapy (OT), IV antibiotics and wound care. He also had dry gangrene of his toes. PT and OT services were discontinued by October 2006 as well as the patients IV antibiotics and his PICC line. The patients wounds were stage II or less and his feet required only once per day dressing changes. There is no indication he required daily skilled wound assessment or more frequent dressing changes.Reviewers Findings:The physician reviewer indicated the patients IV antibiotics were completed and he had not progressed with PT or OT and remained at a functional level I. Although the patient is likely to benefit from daily range of motion and assistance with positioning tolerance, these are non-skilled interventions. With improvement in his medical condition the patient may, at some later date, benefit from additional PT and OT. The patients wounds do not require daily skilled care or frequent dressing changes.  The reviewer decided that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued inpatient psychiatric hospitalization for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or to others.  She was not manic, and had no hallucinations in any modality.  She was not delusional or agitated.  The patient was psychiatrically stable on her medication regimen to the extent that she did not require inpatient level of care.  She was medication compliant.  She did not demonstrate patterns of instability in behavior or eating disorder behavior.  No new problems had arisen.  She participated in groups.  The daily physician progress notes were essentially the same each day.  There was no evidence to suggest that returning her to an environment of assisted living with intensive outpatient level of care would result in an exacerbation of her eating disorder behavior which would result in another inpatient hospitalization.  It should be noted that although she had a history of substance abuse, this issue was not addressed.  The current medical evidence does not support the services at issue in this clinical setting.  All told, continued inpatient psychiatric hospitalization was not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for positron emission tomography (PET) of the whole body. Per the American College of Radiology (ACR) practice guidelines, there is a lack of documentation of biopsy proven primary or metastatic malignancy, indeterminate mass found on other imaging, or any other indications to support the medical necessity of the PET scan. Per the ACR, some indications for PET include staging on presentation for guiding initial treatment strategy in patients with a known malignancy, monitoring  response  to  therapy, restaging in the setting of relapse, or to  localize  the  site  of  primary  tumor  when  metastatic  disease  is the  initial  manifestation  of  malignancy. Additionally, per the ACR guidelines, the records do not report any need to verify and localize occult disease, a need to evaluate an abnormality considered indeterminate by another imaging modality, or an indication to guide treatment goals, biopsy, or radiation therapy. Overall, there is a paucity of large scale studies showing the diagnostic role and efficacy of PET to determine the cause for anemia with hemophagocytosis. Given these findings, the PET of the whole body was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 radiology with subspecialty certification in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MS Contin and hydromorphone for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  This patient has not been compliant with her opiate medication agreement.  She has tested negative for prescribed opiates twice, and tested positive for cannabis and alcohol. She has not complied with going to pain management and psychiatry consultations. Noted the dangers of high dose chronic opiate use and the need for careful supervision and also patient compliance to avoid serious complications. The repeated findings of abnormal urine toxicology shows a clear violation of the agreement. This patient is not a suitable patient for chronic opiate maintenance.  All told, MS Contin and hydromorphone are not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medications 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 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: Overturned

The patient is a 51-year-old female with a left breast mass. A mammogram performed in February 2004 showed a 3cm mass. Ultrasound-guided biopsy was performed with the mass being invasive ductal carcinoma. The patients surgeon ordered a positron emission tomography (PET) scan as part of the staging evaluation. The Health Plan has denied authorization for the requested PET scan.Over the last decade, there have been many studies showing the efficacy of PET for staging breast cancer. In October 2002, the Centers for Medicare and Medicaid Services approved PET scans for breast cancer staging/restaging of local/regional recurrence or distant metastases. PET scan has been shown to be more sensitive and specific than CT scan for detection of mediastinal and internal mammary lymph node metastases. Additionally, PET has been shown to be more sensitive, accurate and have better positive and negative predictive values than conventional imaging for detecting local recurrence or distant metastases.  PET has been shown to have a significant impact on the management of breast cancer patients, influencing both clinical stage and management. In the case of this patient, her provider has requested a PET scan to assess her disease status. A PET scan to assess breast cancer patients such as this patient is medically indicated.Based upon the information set forth above, I have determined that the requested PET scan is medically necessary for evaluation of the patients medical condition. As such, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 63-year-old male has requested reimbursement for intensive care unit (ICU) services provided on the basis the services were emergent in nature. The patients post-operative MRI showed resection of a large mass, but with mild brain edema and slight shift of brain structures from right to left. This suggested that he was still at risk for seizures or other neurologic sequelae and therefore frequent neurological checks were indicated. However, the patient was not experiencing an emergency medical condition as defined above. He was two days post-op and not at risk of immediate harm. The need for ICU care was at the discretion of the operating neurosurgeon as a precautionary measure to monitor the patients neurological status but the ICU services he received were not needed for treatment of an emergency medical condition.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 eight sessions of occupational therapy. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested services in this clinical setting. The medical studies indicate that oral aversion develops in many children, including in healthy children.  Rates are higher in the setting of a relevant medical condition or developmental disability. There are few high-quality studies of these disorders in children whose oral aversion is not sufficiently severe enough to require a feeding tube, as in this patients case.  The patient is well grown and there is no mention in his history of chronic respiratory problems which might indicate chronic aspiration of food or liquid.  There is no laboratory data to demonstrate the presence or absence of micronutrient deficiency, such as iron or vitamin D, which can occur with restricted dietary range. There is also no description of any speech impairment. Moreover, there is a statement in the provided documentation that he had a feeding evaluation performed which indicates that the patient can eat and drink safely.  It is unclear whether the evaluation performed included a fluoroscopic evaluation as well as a bedside/clinic evaluation. In this patients case, the documentation does not demonstrate that he is malnourished or has inadequate oral motor skills, or that he has mucosal damage from frequent vomiting.  In the absence of such findings, eight sessions of occupational therapy is 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 board certified in pediatrics with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test provided for evaluation of his esophageal adenocarcinoma. Findings:  Three physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis for other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, it would be considered investigational/experimental for this patient. Many clinical trials would not require molecular profiling, especially many immunotherapy trials. As such, FoundationOne gene test provided was not likely to have been more beneficial than the standard of care for the evaluation of this patient. Final Result: Three reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty 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: Upheld

The patient is a 22-year-old female with right upper quadrant pain. She has associated nausea with the pain. On physical exam, some right upper quadrant and flank pain was present. Two ultrasounds performed in June 2004 and September 2004 were negative. A CT of the abdomen and pelvis was also negative. The patient has requested coverage for a third ultrasound, which the Health Plan has denied stating the requested ultrasound is not medically necessary for evaluation of the patients medical condition. The requested ultrasound is not medically necessary for this patient. She has had two negative ultrasounds, and also a negative CT scan. All of the patients labs have been essentially negative. A repeat ultrasound in this patient at this time will not add any new information to help with her diagnosis. Therefore, I have determined that the requested ultrasound is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for baby formula Alimentum (HCPCS B4161-EF ped hydrolyzed/amino acid) for treatment of the enrollees milk protein allergy. Findings:  The physician reviewer found that based on this patients medical history and the documentation provided for review, the requested Alimentum formula is medically necessary. This patients declining weight-for-age percentile is concerning for pending growth failure. There is evidence in the medical records of a milk/soy protein allergy, which is a clinical diagnosis and cannot be identified on the basis of laboratory testing. An extensively hydrolyzed formula is sufficiently hypoallergenic to be tolerated by 95% of infants with this condition. However, even when well-tolerated in regard to symptom control, extensively hydrolyzed formulas may not be palatable. When an infant is orally fed, and refuses the appropriate formula, growth failure can result. As this patient has refused Nutramigen formula, the requested replacement Alimentum is supported as medically necessary. Final Result: The reviewer determined that the requested service is 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 pediatrics with sub-specialty certification in 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: Upheld

A sixty-nine year-old male with posterior right knee pain is requesting authorization of an MRI of the right knee.  An examination note documented the request for a right knee MRI. However, there was no description of physical findings and there was no documentation of failed conservative treatment.Reviewers Findings:The reviewing physician found that the record submitted for review contained no documentation of a complete physical examination or of a diagnosis.  Nor does it appear that an ultrasound was performed.  Without this information an MRI of the right knee is not medically indicated.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.