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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy for six months, nine hours per month of caregiver training for six months, 16 hours per month of supervision for six months and eight hours per month to conduct clinical team meetings for six months for treatment of the autism spectrum disorder. Findings: The physician reviewer found that based on the clinical documentation submitted for review, 40 hours per week of one-on-one ABA therapy for six months, nine hours per month of caregiver training for six months, 16 hours per month of supervision for six months and eight hours per month to conduct clinical team meetings for six months is medically necessary for treatment of the patients autism spectrum disorder. Children and adolescents with autism spectrum disorders have a high rate of irritability and aggressive symptoms (Robb). Matson and colleagues note that because of the increased physical size of older children and longer history of problems, treating these behaviors effectively is important. In addition, severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and that behavioral interventions can significantly reduce such behaviors. In this case, the patient continues to have several behaviors that pose a danger to self and others, including aggression, self-injury, property destruction and elopement. While there has overall been a documented improvement in behavior, several behaviors still warrant a comprehensive level of support. Although the patients tantrums have decreased in frequency, this behavior has increased in duration. As such, the requested services have been established as medically necessary for treatment of the 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 pediatrics and 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

A thirty-four year-old female with a history of autoimmune disorder and recurrent miscarriage is requesting reimbursement for the IVIG therapy.  Reviewers Findings:  The reviewing physician determined that treatment with IVIG for recurrent miscarriage has not yet been shown to be clearly effective.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 78-year-old female enrollee has requested for hernia surgery for treatment of her hernia. Findings:  The physician reviewer found that bowel resection is a high risk procedure. Many patients with large herniae can be followed if their anatomy is such that the contents do not obstruct or strangulate. The patients age, weight and multiple comorbidities all support a nonoperative approach, unless symptoms worsen and increase in frequency. Based upon the information, surgical intervention is not medically indicated or appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested for a PET/CT scan for evaluation of her breast cancer. Findings:  The physician reviewer found that treatment monitoring and re-staging of breast cancer. PET/CT scan has been shown to be more sensitive and specific than CT scan for detection of mediastinal and internal mammary lymph node metastases. PET/CT scan has also been shown to be more sensitive, specific and accurate and to have better positive and negative predictive values than conventional imaging for detecting local recurrence and distant metastases. PET/CT scan has a significant impact on the care of breast cancer patients, influencing both their clinical stage and their treatment management.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Synvisc-one injection in the right knee. The enrollee has a history of osteoarthritis of the right knee. He underwent a right knee arthroscopy, with a partial medical meniscectomy, and a left total knee replacement, after which he developed blood clots. His pain is aggravated by prolonged standing and walking. He has received Synvisc-one gel injections in the past. A professional society reports the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who are not good surgical candidates or who do not respond to other treatment options. This enrollees medical records show considerable arthritis in both the medial and lateral compartments. The enrollee has also failed previous non-surgical treatment; including arthroscopic surgery. The requested Synvisc-one injection is a qualified non-surgical option to help avoid a total knee arthroplasty for this enrollee at this time.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Butrans patch. This patient has chronic abdominal pain and is currently under the care of a pain management specialist for his abdominal pain and intercostal neuralgia. He has been treated with Percocet and Norco for pain control, but these were ineffective. His provider as prescribed the Butrans patch due to its more favorable side effect profile, 24-hour formulation, and because it bypasses the gastrointestinal system. A recent peer-reviewed medical literature validates the efficacy of buprenorphine for use in chronic pain population and current consensus guidelines support using buprenorphine as first line treatment over traditional full opioid agonists due to better safety profile, tolerability, and non-inferior analgesic effects. This therapy is consistent with the current Centers for Disease Control (CDC) guidelines on opioid therapy, which advocate starting patients on the lowest effective dose of opioids as part of a multi-modal pain management strategy. This patients provider is managing this patient in a manner consistent with current practice guidelines and has selected the transdermal formulation, which is appropriate for this patient with gastrointestinal intolerances. For these reasons, the requested Butrans patch is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication 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 anesthesiology with subspecialty certification in pain management 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 47-year-old female enrollee has requested physical therapy (PT) for the treatment of her laminectomy and spinal fusion. Findings:  The physician reviewer found that the submitted physical therapy notes do not reflect any changes in the type of therapy, but simply demonstrate a gradual increase in the number of repetitions to be performed for a designated exercise. The patient had been instructed in a home exercise program (HEP) by this time. The documentation does not support the on-going need for skilled PT services. The patient could have continued her HEP independently by that point in her therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee has requested Procrit for treatment of her anemia.  Findings:  Two physician reviewers found that based on the blood work and bone marrow biopsy report, his condition is consistent with pure red cell aplasia. While the presence of a high platelet count is not characteristic, it does not rule out the diagnosis. The record provided for review does not include documentation of a computed tomography (CT) scan to rule thymoma, which also should be ruled out. In addition, there is a paucity of scientific data demonstrating the safety and efficacy of recombinant erythropoietin in the management of red cell aplasia.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male has requested coverage for a hip resurfacing procedure for treatment of osteoarthritis.  Findings:  The physician reviewer found that surgical treatment options for this patient included total hip replacement and total hip resurfacing. Based on the patient's young age, body habitus and activity status, he would indeed be considered a candidate for hip resurfacing. As noted by the Health Plan, metal-on-metal total hip resurfacing with an FDA approved device is a viable alternative to total hip replacement in patients who are candidates for total hip replacement and are likely to outlive a traditional prosthesis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care services provided during a colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a routine screening colonoscopy. There was no documentation of a history of significant heart, lung, kidney, or liver disease, or of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation documented in the submitted records. The patient had an ASA classification score of 3; however, the submitted records did not document severe systemic disease processes to support this documentation. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, monitored anesthesia care services provided during a colonoscopy were not medically necessary 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 anesthesiology 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 58-year-old female enrollee requested a computed tomography (CT) scan, electrocardiogram (EKG) and bacterial (BACT) testing for medical treatment of her abdominal pain and urinary tract infection. Findings:  The physician reviewer found that given the lack of exact definitions or criteria for non-ST elevation acute coronary syndrome, particularly in middle-age women such as this patient, who often present atypically, the EKG was clinically indicated. In addition, per the American College of Radiology, the disputed CT scan was indicated for the patients presenting symptoms of a three-day history of abdominal pain.  Also, in the case of urinary tract infection, bacterial testing is critical in determining the choice and appropriateness of antibiotic treatment (Schmiemann, et al). In sum, the services provided to the patient at the time of her ED presentation were clinically warranted and medically necessary. Therefore, the medical necessity of the services at issue has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Orthovisc injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The researchers reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Given this support, the requested Orthovisc injections are supported as 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 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

The parent of a 2-year-old male enrollee has requested 1 hour of occupational therapy per week for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. The patient is a 2-year-old male with a diagnosis of autism and he is receiving 15 hours of ABA therapy and 1 hour of speech therapy per week. OT was initiated on the date indicated at a frequency of 1 hour per week. OT is effective in reducing many of the unwanted mannerisms associated with autism. In this case, the initial OT evaluation recommended the use of sensory integration techniques. Studies are inconclusive as to when formal sensory modulation therapy should be initiated. The efficacy of this therapeutic modality in very young children, such as this patient, has not been clearly established. An in-Plan provider recommends a home OT program in cooperation with the patients ABA therapists. Based upon the documentation submitted for review, it is medically reasonable to implement a home OT program at the present time. However, the patient should undergo OT reevaluation in 6 months to determine his needs at that time. As such, a home program is medically reasonable at the present time and the patient should be reassessed in 6 months to determine if he is an appropriate candidate for participation in a formal OT program. Accordingly, the requested therapy is not medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested speech therapy, occupational therapy and feeding therapy for treatment of his autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for this patient with autism who has a moderate impairment of pragmatic speech and socialization deficits.  Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Rogers and Vismara). Currently, effective interventions exist to teach communication skills to children with autism (Goldstein). Language skills make a significant difference in the ability of children to control their environment and have been found to be an adaptive alternative to highly disrupted behaviors, as noted in this patient. Therefore, speech therapy is a medically necessary component of this patients treatment plan.With regard to the request for occupational therapy, a fine motor evaluation found the patients fine motor skills to be within functional limits for his age; gross motor skills were also age-appropriate. Occupational therapy to treat the sensory processing deficits in this patient is not medically necessary, as the efficacy of this therapy for sensory processing deficits remains unproven. Sensory integration therapy is sometimes used alone or as a part of a broader program of occupational therapy for children with autism spectrum disorders (Myers, et al. and Baranek). While unusual sensory responses are common in children with autism spectrum disorders (ASD), the efficacy of sensory integration therapy has not been demonstrated objectively. (Myers, et al.; Baranek; and Polatajko, et al.) Concerning the requested feeding therapy, the medical necessity of this modality is not established in this case. Concerns about food selectivity are typical in patients with autism spectrum disorder. According to the submitted physical evaluation, the patient has normal weight and height growth velocities. The patients feeding issues do not rise to a level that necessitates implementation of a therapeutic feeding program. Based upon the documentation provided, feeding therapy is not clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an electric power scooter. Findings:  The physician reviewer found that there are no medical indications in the submitted records to establish the patient would be bed confined without a power mobility device. According to the documentation, the patient has health conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device would encourage. This was addressed in his primary care clinic visit, where health goals of keeping blood pressure under 140/90 and keeping his weight down were discussed. Per the patients documentation, there is no significant pertinent neurological or musculoskeletal impairments that would preclude ambulation with a cane or walker. There are no indications in the records to establish that the patient would be bed confined without a power mobility device. The patient has no significant pertinent neurological or musculoskeletal impairments that would preclude ambulation with a walker. There are also no significant pertinent neurological or musculoskeletal impairments that would preclude self-propulsion of an appropriately fitted manual wheelchair. Therefore, the requested electric power scooter is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to an orthopedic specialist that provides tertiary level of care. Shoulder pain is common in the general population. Reports show the prevalence of one months history of persisting shoulder pain is between 7% and 26%. Furthermore, 40% of patients continue to complain of pain one year after primary care evaluation and treatment. When referred to an orthopedic shoulder specialist, the patient is likely to undergo treatment with a corticosteroid injection, exercise, or surgery with greater chance of success. In this case, there is evidence of a recent shoulder dislocation and a rotator cuff tear involving the supraspinatus tendon. Additionally, there is evidence of glenohumeral joint cartilaginous thinning. In light of these multiple problems, referral to an orthopedic shoulder specialist providing a tertiary level of care is appropriate for management of this patients worsening left shoulder pain. Therefore, the requested referral to an orthopedic specialist that provides tertiary level of care 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 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.