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

A 49-year-old female enrollee has requested orthotic foot inserts L3020 x 2-foot longitude/metatarsal support (removable foot inserts) for treatment of her foot pain. Findings:  The physician reviewer found that the requested orthotic foot inserts are indicated for this patients continued pain.  Limited documentation was submitted for review. However, in a letter, the patients podiatrist noted that the patient has ongoing symptoms of tendonitis and neuritis in the foot and ankle which have not resolved completely. He also noted that the patient has had injections.  She has been diagnosed with plantar fasciitis, neuritis and painful hallux valgus. These painful foot conditions can be treated conservatively and successfully with the use of custom triplanar orthotics. In this patients case, orthotic foot inserts L3020 x 2-foot longitude/metatarsal support (removable foot inserts) are medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to impulsivity and substance abuse. In terms of functional status, the records support a score of 3. The patient had moderate functional impairment due to conflict with his mother and lack of engagement with schoolwork. With regard to comorbidity, the records support a score of 2. The patient had a recent relapse with alcohol use as well as symptoms of attention deficit/hyperactivity disorder, anxiety, and depression. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to sheltering-in-place due to the COVID-19 pandemic and discomfort with expectations set by his mother and the Intensive Outpatient Program. With regard to the level of support of the recovery environment, the records support a score of 2. The patient had a supportive environment due to his mothers participation in the program. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to persistence of symptoms despite extended and intensive treatment exposure. With regard to treatment acceptance and engagement of the patient, the records support a score of 4. The records noted a lack of participation in treatment. Thus, the patient has a total score of 19. The records support Intensive Outpatient Program level of care in this setting. Therefore, the Intensive Outpatient Program (IOP) services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent 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

The patient is a 51-year-old female who has requested authorization for a neuromuscular stimulator and supplies. The patient is experiencing shoulder and arm pain after an injury in September 2003. She has also been diagnosed with myofascial pain syndrome. The Health Plan has determined that the requested equipment is not medically necessary for treatment of the patients medical condition.There are no randomized, controlled, peer-reviewed outcome trials demonstrating the efficacy of neuromuscular stimulation for treatment of myofascial pain syndrome. Thus, it is unlikely that a neuromuscular stimulator will be of any benefit in this case. The Health Plans recommendation that the patient undergo a workup with a physiatrist and/or a neurologist is medically reasonable and appropriate. There is no medical indication for a neuromuscular stimulator in this clinical setting. Therefore, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male enrollee requested partial hospitalization program (PHP) services for medical treatment of his alcohol dependence.   Findings:  The physician reviewer found that this patient did not meet the American Psychiatric Association (APA) or American Society of Addiction Medicine (ASAM) treatment criteria for PHP treatment. The patient was not at imminent risk for withdrawal on admission. He was not suicidal, homicidal, or psychotic. He was motivated and engaged in his care. He was medically and psychiatrically stable. He was working on Step I and had a temporary sponsor. He experienced cravings but no other symptoms of withdrawal and he declined medications. Although it was reported that he lived in an area where IOP and AA was unavailable locally, he could have safely and adequately been treated in the outpatient setting with concomitant counseling and the sober support system of his family. All told, he did not meet medical necessity criteria at a PHP level of care. Thus, the PHP services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, residential treatment center services, on the dates at issue, were not medically necessary for treatment of the patients behavioral health conditions. Initially the patient had many symptoms that resulted in her admission, however, subsequently, she appeared to stabilize. Medications continue to be adjusted, however, none of the medication adjustments required treatment at the level of residential care. All told, the patient did not require 24 hour supervision for psychiatric treatment. There was no reasonable expectation that the patients symptoms or level of functioning would have significantly improved with residential care. Given the above, the services at issue were not medically necessary for treatment of the patients medical 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 with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old female enrollee has requested genetic testing (chromosomal microarray) for an evaluation of the enrollees chromosomal anomaly. Findings:  Three physician reviewers found that developmental delay reportedly has a prevalence rate of about 3.5%, but the cause is unknown in up to 70% of cases. The diagnostic yield of conventional cytogenetics is less than 5%, and FISH is approximately 7%. With the advent of microarray-based cytogenetics, the positive yield has increased to 15-20%. The use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders. Microarray-based cytogenetics should be the first line test for these types of patients, except those suspected of having classic whole chromosome aneuploidy, such as Downs syndrome or Turner syndrome (Li and Andersson). It was not until this patient was evaluated using microarray-based cytogenetics that her genetic abnormalities were identified. As a result of this testing, appropriate follow-up can now be arranged for her and genetic counseling can be provided to the family. In conclusion, the diagnostic testing at issue performed (chromosome microarray analysis) was more beneficial for evaluation of this childs condition than other standard therapies, and is the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for stress echocardiogram. Findings:  The physician reviewer found that The records report that this patient was referred by his provider for stress echocardiography for evaluation of his longstanding and extensive coronary artery disease (CAD). He is 25 years post coronary artery bypass graft (CABG) and has known occluded bypass grafts. Although he is asymptomatic at present, he has known un-revascularized disease with multiple occluded grafts and significant prior left ventricle (LV) dysfunction. Thus, reassessment of his LV ejection fraction, along with any ongoing ischemic burden, would be useful and beneficial to his management. If he has viable myocardium despite the depressed ejection fraction, his cardiac function may benefit from repeat cardiac catheterization and possible revascularization. Assessment of ongoing ischemia versus infarction by stress echocardiogram will help provide this information which would inform further treatment decisions. Given this support, the requested stress echocardiogram is medically necessary for 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 internal medicine with subspecialty certification in cardiovascular disease 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 bilateral hip replacement surgery for treatment of the enrollees bilateral hip osteoarthritis.  Findings: The physician reviewer found that the records indicate that the patient is medically stable and bilateral hip replacement is indicated for her medical condition. The patients records do not suggest that she is unstable for surgery. Patients with hip osteoarthritis have high disability levels and substantially impaired health-related quality of life. Her nutritional indices are borderline, but have been stable over a number of months. Given her current medical issues, the patients nutritional status may not improve significantly. Total hip replacement is indicated in this patient with severe pain and disability who has exhausted conservative treatment, is medically stable, and a reasonable risk for undergoing major surgery. Accordingly, the requested bilateral hip replacement surgery is supported as medically necessary for treatment of this patients hip osteoarthritis.Final Result: The reviewer determined that the requested surgery 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for destruction by neurolytic agent (CPT 64640 x 2) and chemodenervation of eccrine glands (CPT 64650 x 2). Findings:  Two of the three physician reviewers found neuralgia is a type of neuropathic pain. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia specifically refers to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. This patient has been diagnosed with occipital neuralgia on examination. Another key element to the diagnosis is response to occipital nerve blocks. Per the records, this patient did not sustain permanent relief following the injection. There is data to suggest that oral agents, such as carbamazepine, gabapentin, and tricyclic antidepressants, can be effective. On 3/07/18, the patient reported that gabapentin was effective. All told, the requested destruction by neurolytic agent (CPT 64640 x 2) and chemodenervation of eccrine glands (CPT 64650 x 2) are not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 21-year-old female with a body mass index (BMI) of 55. She is requesting authorization for gastric bypass surgery. The patient also has a number of comorbid conditions. The patient indicates she has made multiple attempts to lose weight without long-term success. The Health Plan indicates it is medically necessary for the patient to meet her preoperative weight loss goal prior to undergoing bariatric surgery. The Health Plans denial should be overturned. There is not significant additional risk to the patient if she weighs 340 pounds versus 317 pounds when gastric bypass surgery is performed. There is no randomized, blinded study demonstrating that preoperative weight loss results in a better clinical outcome. There is no specific medical reason to require the patient to undergo preoperative weight loss from a technical or evidence-based point of view. Therefore, I have determined that it is not medically necessary for the patient to meet her preoperative weight loss goal prior to authorization of bariatric surgery. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital stimulator implantation of electrodes. The criteria for diagnosis of occipital neuralgia require severe paroxysmal, lancinating pain in the distribution of the occipital nerves, a positive Tinels sign, and dysesthesia with palpation. This patient does not meet the criteria since her pain is chronic, occasionally shooting to the eye, and there is no documentation of a positive Tinels sign or dysesthesia with palpation. Overall, the records do not support a diagnosis of occipital neuralgia. Moreover, surgical occipital nerve stimulation is not consistent with the current standard of care. Given these findings, the requested occipital stimulator implantation of electrodes is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: One reviewer found that the requested occipital stimulator implantation of electrodes is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two of the three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: One reviewer is board certified in neurosurgery and is actively practicing. One Reviewer is board certified in neurosurgery and is actively practicing. One Reviewer is board certified in neurosurgery and is actively practicing. All three 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

A 61-year-old male enrollee has requested inpatient, sub-acute psychiatric residential treatment for treatment of his bipolar disorder.  Findings:  The physician reviewer found that this patient had been having mood symptoms over six months prior to the self-referral to this program. There were no precipitating events or issues. He had no acute symptoms and no relapse in either illness. The contention that the inpatient intervention was to be preventive of a relapse is not supported in the clinical records.  This patient could have been managed at a lesser level of care, such as a partial hospitalization program.  The submitted documentation does not establish the medical necessity of the services at issue. All told, inpatient, sub-acute psychiatric residential treatment provided from the dates in question was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for immunotherapy (allergy shots once per week for 52 weeks, two injections per visit). Allergy shots are indicated for persistent symptoms on a seasonal and/or perennial basis and those with an inadequate or partial response to environmental control and medications. Current guidelines recommend skin testing and allergy shots as an effective treatment for allergic rhinitis, asthma and atopic dermatitis. The intervals between maintenance immunotherapy injections generally range from four to eight weeks for venom and every two to four weeks for inhalant allergens but can be advanced as tolerated if clinical efficacy is maintained. In this case, the medical records indicate that the patient is on maintenance therapy. The patients response to immunotherapy, percent improvement and any adverse reactions during build-up are not noted. The maintenance therapy is for inhalant allergies and would typically be every four weeks up to every two weeks if needed. The medical records fail to demonstrate the need for weekly injections during the maintenance phase. As such, the request for authorization and coverage for immunotherapy (allergy shots once per week for 52 weeks, two injections per visit) is not medically necessary.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 allergy and immunology 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 coverage for the following inpatient neuro-rehabilitation treatment program services: physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management and family counseling and education. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient is likely to benefit from a facility dedicated to neuro-rehabilitation. Per the records, he is displaying symptoms that are behavioral as well as cognitive secondary to anoxic brain injury from carbon monoxide poisoning. Neuro-rehabilitation programs typically have a team-based approach to treating neurobehavioral problems. These teams usually include psychologists, psychiatrists, social workers, occupational therapists and physical therapists. The use of specialized mental health workers is unique to neuro-rehabilitation facilities. This patient requires inpatient level of care as he poses a danger to himself and others. He requires constant supervision. The requested services are medically appropriate in this clinical setting. Therefore, the following inpatient neuro-rehabilitation treatment program services: physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management and family counseling and education are 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 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 58-year-old male enrollee has requested platelet rich plasma treatments for treatment of his hip osteoarthritis.  Findings:  The physician reviewer found that prolotherapy is noted to be used in treating ligaments, tendons, muscles, and joints. In the article authored by Sheth and colleagues, a meta-analysis of 23 different randomized trials and 10 prospective cohort studies were reviewed. The authors found a lack of consistency in outcome measures across all studies. Visual analog scores were used in many of the studies comparing platelet rich plasma with alternative injection therapies. These authors concluded that platelet rich plasma provided no significant benefit up to and including 24 months across the randomized trial. In this case, the patient presents with bilateral degenerative osteoarthritis of the hips. There is little consensus that platelet rich plasma would be effective and beneficial in management of the patients bilateral degenerative osteoarthritis of the hips. All told, it is not medically necessary for the patient to undergo the proposed series of platelet rich plasma injections.
Appeal type: Experimental/Investigational
Decision: Upheld

A 76-year-old male has requested cryoablation of the prostate for treatment of prostate cancer. Findings:  Two physician reviewers found that it is unlikely that cryoablation will be more successful than conventional treatments such as external beam radiation or brachytherapy. There is no evidence establishing the long-term effectiveness of this procedure in the treatment of prostate cancer, and it has not been shown to be more effective than traditional treatment approaches. Cryoablation is generally more successful as a secondary treatment for prostate cancer that has failed radiation.