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

A 52-year-old male enrollee has requested continued acute rehabilitation services for treatment of his subacute cerebral vascular accident (CVA) with right hemiparesis and expressive aphasia.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of continued acute rehabilitation services. This patient had a stroke and has received several weeks of rehabilitation with significant functional gains. According to the Centers for Medicare and Medicaid Services (CMS), continued inpatient acute level rehabilitation is appropriate for individuals who require access to rehabilitation nursing services 24-hours per day and in whom there is an expectation of significant measureable improvement over a prescribed period of time. This patient is at the modified independent wheelchair mobility level and requires minimal assistance for toileting, grooming and bathing.  Thus, significant improvement is not expected based upon the substantial progress that has already been made. Further, based upon the records provided, the patient does not have any medical needs that require access to 24-hour nursing care. Although the patient has continued rehabilitation needs, such issues can be appropriately addressed at a lower level of care. Based upon the documentation provided, the medical necessity of continued rehabilitation services has not been established. As such, the requested services are not considered medically necessary.
Appeal type: Urgent Care
Decision: Upheld

A 60-year-old male enrollee requested services provided on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention.  The patient presented with reported symptoms of itching and jaundice for more than 20 days. There is no documentation during this pre-hospitalization window, nor immediately following hospitalization, of hemodynamic instability, respiratory compromise, or shock which might necessitate emergent treatment. In addition, the records do not support that an emergency medical condition existed at the onset of symptoms or in the early days of hospitalization.  All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested for oral appliance therapy for treatment of her sleep apnea. Findings:  The physician reviewer found that The long-term prospective study published by Guilleminault and colleagues supports the fact that many patients such as this patient may go on to progress to more severe sleep disorders as well as mood disorders. Mandibular positioning devices are known to be useful in treatment of mild to moderate obstructive sleep disorders. Compliance is fairly good when compared to the use of CPAP, and clinical symptoms show significant reduction with this treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee requested authorization and coverage of a surface replacement arthroplasty utilizing a metal-on-metal device. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees osteoarthritis.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested for participation in clinical trial CC06451 entitled A Phase I/II Study of Fixed-Dose Rate of Gemcitabine Plus Bevacizumab for Postoperative Adjuvant Treatment of Patients with Resected Pancreatic Cancer for treatment of his pancreatic cancer. Findings:  The physician reviewer found that Gemcitabine has been found to be effective as a single agent in the adjuvant treatment of pancreatic cancer. However in the treatment of metastatic pancreatic cancer, adding bevacizumab to gemcitabine was not found to be better then gemcitabine alone. While the proposed clinical trial is an interesting study, at this time there is insufficient data to suggest that adding bevacizumab to gemcitabine will improve the adjuvant treatment of pancreatic cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a left foot x-ray for evaluation of her medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  While it is likely that motor deficits of foot drop and changes in sensation in the left foot are determined primarily by residuals of compartment syndrome and peroneal nerve injury, an x-ray of the left foot will establish the presence of normal skeletal anatomy.  If there is no evidence of fracture, then appropriate orthotics and possible surgical stabilization may be necessary.  The medical records document severe stab wounds with soft tissue and neurological injury.  All told, the requested left foot x-ray is medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly parent-child interaction therapy, weekly child-directed therapy (CDI), weekly verbal directed therapy (VDI), weekly Fad-ins, and community exposure. Findings:  The physician reviewer found that records provided for review document that this patient has a history of anxiety, selective mutism, difficulty engaging in social settings and communication with others. The patients provider has recommended treatment with parent-child interaction therapy, CDI, VDI and Fad-ins with community exposure. This therapeutic regimen is consistent with recommendations in the medical literature. Muris and Ollendick describe that selective mutism is characterized by a consistent failure to speak in specific settings (e.g., school, social situations) despite speaking normally in other settings. Oerbeck and colleagues noted that selective mutism is considered difficult to treat. The authors found that in-person with the patient for 12-16 weeks yielded gains that were largely maintained in a five-year follow up. Catchpole and colleagues reported on a cohort of 33 children with selective mutism who were treated with parent-child interaction therapy principles and behavioral techniques. The authors reported that, Results showed significant and large gains in speaking behaviors across contexts from pre- to post-treatment. Moreover, the requested therapy services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, the requested weekly parent-child interaction therapy, weekly CDI, weekly VDI, weekly Fad-ins, and community exposure is medically necessary for 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 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: Upheld

The parent of a one-year-old male enrollee has requested authorization and coverage for circumcision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee, who was born prematurely. Findings:  The physician reviewer found that there is significant debate regarding the necessity of neonatal circumcision.  According to a report published by the American Academy of Pediatrics, although the current scientific evidence demonstrates potential medical benefits of newborn male circumcision, these data are not sufficient to recommend routine neonatal circumcision.  As noted by Kleigman and colleagues, circumcision is often recommended for infants who are predisposed to urinary tract infections, such as those with congenital hydronephrosis and vesicoureteral reflux.  The submitted documentation fails to establish the medical necessity of the requested procedure in this case.  This patient does not have any urogenital abnormalities or history of infection. All told, circumcision is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anterior lumbar interbody fusion L5-S1 for treatment of her L5-S1 degenerative disc disease. The physician reviewer found that review of the submitted documentation does not establish the medical necessity of anterior lumbar interbody fusion L5-S1. Flexion extension films have not demonstrated instability. In addition, there is limited localization of structural changes at L5-S1 as opposed to a more generalized pain generation at more proximal levels as well as L5-S1. The anatomical studies do not emphasize spinal stenosis, either central spinal stenosis or neural foraminal stenosis. As discussed in the medical literature, chronic regional pain treated with single level focal surgical procedures is not likely to be efficacious because of the multifactorial nature of chronic lumbosacral pain. There are also substantial risk factors associated with an anterior approach which expose the patient to potential injury to iliac veins and ureter. The literature does not demonstrate that the requested anterior lumbar interbody fusion L5-S1 will result in a better outcome in the setting of chronic regional lumbosacral pain syndrome than continued conservative care. Accordingly, the requested service is not medically necessary for treatment of the patients medical condition. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the hormone implants (subcutaneous testosterone implants) for treatment of the enrollees hypogonadism. Findings:  The physician reviewer found that the Endocrine Society guidelines recommend testosterone therapy for symptomatic men with classical androgen deficiency syndromes aimed at inducing and maintaining secondary sex characteristics and at improving their sexual function, sense of well-being, and bone mineral density.Testosterone pellets were approved by the U.S. Food and Drug Administration (FDA) and have been proven to be effective at doses up to 10-12 pellets every three to four months in well selected patients.  This patient has proven low testosterone levels. In addition, the patient has not responded adequately to transdermal therapy. His levels remained subnormal and he continued symptomatic. All told, the testosterone pellets were properly administered to this patient with low testosterone levels that failed to transdermal preparations. Given these findings, the hormone implants (subcutaneous testosterone implants) were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the reviewers determined that the service at issue was 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 reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 46-year-old male enrollee has requested a continuous passive motion machine for treatment of his arthrofibrosis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  The efficacy of a continuous passive motion machine following knee surgery has not been demonstrated in this clinical setting.  There is a paucity of evidence supporting the use of the equipment at issue in this patients case.  No significant difference between the range of motion in patients undergoing anterior cruciate ligament reconstruction with or without continuous passive motion has been demonstrated, and no advantage was found with or without its use.  The current medical evidence does not support the use of the continuous passive motion machine in this clinical situation.  All told, the continuous passive motion machine provided was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A fifty-four year old female who had a subtotal resection of a left frontal grade III anaplastic astrocytoma, followed by radiation therapy and chemotherapy, subsequently developed a progressive gait disturbance and mild right-sided hemiparesis . Contrast MRI and PET/CT could not exclude metastatic tumor. The treating radiation oncologist along with a consensus of Neurosciences Conference physicians recommended MRS of this region to distinguish tumor recurrence from delayed tissue effects of prior irradiation. Reviewers' Finding:Two of the three physician reviewers found MRS is frequently performed to differentiate active tumor from necrotic tissue and that MRS is not considered experimental or investigational in this instance and is superior to other diagnostic modalities in its ability to discern the metabolic pattern of an active tumor.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested a continuous positive airway pressure (CPAP) machine for the treatment of his sleep apnea. Findings:  The physician reviewer found that this patient has clear symptoms of obstructive sleep apnea and his sleep study had an AHI of 12.  Based upon these findings, the patient meets accepted criteria for authorization of CPAP. The utilization of CPAP is medically indicated and prudent for effective treatment of this patients documented sleep apnea.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the substance abuse residential treatment services she received. Findings:  The physician reviewer found that the requirements for inpatient treatment for alcohol withdrawal and continuing substance abuse treatment rely on indications of severe withdrawal symptoms, comorbidities, and the presence of environmental instabilities, the duration of alcohol abuse, and the history of severe withdrawal symptoms such as delirium tremens or hallucinosis. The records provided for review document that this patient had a long history of alcohol abuse, but also had a successful extended period of abstinence, with evidence of good response to previous outpatient treatment. She was not suicidal, homicidal, or displaying severe withdrawal symptoms. She was a candidate for treatment in a less restrictive treatment setting and did not meet the criteria for residential detoxification and treatment. She was being actively treated for comorbidities and there is no indication that she was deteriorating. Medications prescribed for her bipolar disorder and PTSD could have been adequately and safely managed on an outpatient basis. All told, the substance abuse residential treatment services provided were not medically necessary for treatment of this patients behavioral health condition. 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

A 27-year-old male enrollee has requested surgical repair of his soft palate for treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that current clinical criteria for nasal surgical intervention and uvulopalatopharyngoplasty can be met with documentation of apnea/hypopnea index in the moderate OSA category (between 15-30 episodes/hour of sleep). According to the medical reports reviewed, the patient has not had any significant complaints of laryngeal obstruction or functional problems and there is no documentation of a trial of conservative management to improve such problems. Although the patients Health Plan has approved the surgical repair of the nasal septum, in the absence of a recent sleep study (performed within the last year) documenting moderate OSA, there is no indication to add the secondary procedure at the same time as the planned surgical repair of the nasal septum.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for high frequency chest compression device. Findings:  The physician reviewer found that available documentation supports that this patient presents with significant neurologic and neuromuscular sequelae due to intracranial hemorrhage in infancy. The patient has inadequate airway clearance and requires assistance to mobilize secretions and prevent aspiration with subsequent pneumonia. The provider indicated that the patient has responded well to treatment with high frequency chest wall oscillation, with more manageable secretions and improved comfort. In addition, the peer-reviewed medical literature supports use of high frequency chest wall oscillation in well selected patients with neuromuscular disorders. High frequency chest wall oscillation was developed to improve airway clearance for use when normal mucociliary transport systems fail, as in this patients clinical setting. Fitzgerald and colleagues evaluated high frequency chest wall compression therapy in children with neurological impairments. The authors found that regular high frequency chest wall compression therapy may reduce the number of hospitalizations in neurologically impaired children. Lechtzin and colleagues commented that treatment with high frequency chest wall oscillation in patients with neuromuscular disease resulted in fewer hospitalizations and cases of pneumonia. The authors concluded that, our findings lend support to the routine use of this intervention in the care of patients with neuromuscular diseases. For these reasons, the high frequency chest compression device was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment at issue was and 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 subspecialty certification in pediatric critical care 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 parent of a 14-year-old male enrollee has requested more than 4 hours per day of shift nursing care services and 8 hours per day of skilled nursing care for treatment of the enrollees myasthenia gravis. Findings:  The physician reviewer found that this patient has congenital myasthenia gravis (MG) with clinical symptoms significant enough to warrant the type of nursing care defined as skilled. Although the patients needs may not require acute or intensive care at this time, the concept behind skilled home nursing care is to prevent regression of his condition to the point where hospitalization is needed. This translates into best medical practice and the standard of care indicated for this patient is skilled nursing care from the said date and forward. The patients records clearly document the need for skilled nursing care in order to maintain a severely compromised airway. As noted by Hardy and Rittenberry of caring for patients with MG, Nursing care is complex and involves patient education about drug therapy and treatment options as well as caring for the numerous problems that arise from varying degrees of muscle weakness. The authors also found that, Skilled nursing assessment and intervention can help protect the myasthenic patient from the life-threatening complications of respiratory compromise. Thus, based on review of the literature and the details of this case, skilled nursing care was and is indeed medically necessary for this patient with congenital MG. The requested 8 hours of skilled nursing care per day have been shown to be medically necessary for this patient