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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential mental health treatment for treatment of her behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Initially, this patient had a formidable psychiatric history characterized by behavioral dysregulation, impulsivity, mood symptoms and substance use that impacted multiple functional domains and jeopardized her developmental task of identity formation.  Subsequently, the patient began making positive strides in her recovery, family therapy and trauma processing.  The patient had a positive attitude in group.  She had a sponsor.  She was nervous about transition but focused in thought and appropriate in presentation.  She was committed to recovery and demonstrating good insight.  The patient was neither suicidal nor homicidal.  The patient was compliant with program rules, actively engaged in treatment, and appropriately interacting with peers. Her family was supportive and engaged in the recovery program.  Based on the documentation provided, the patient warranted ongoing comprehensive specialty care.  However, the illness burden no longer demanded placement in a 24-hour supervised setting. As such, discharge to a less restrictive setting would have been safe, appropriate and consistent with good medical practice in the United States.  Thus, residential mental health treatments were medically necessary initially, but not thereafter.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 54-year-old female enrollee has requested for a sacroiliac joint injection and continued sacroiliac joint injections for treatment of her pain. Findings:  The physician reviewer found that Conservative therapy, including medications and physical therapy, has failed to relieve the patients pain.  The current medical evidence supports the services at issue in this clinical setting.  Dreyfuss and colleagues noted that diagnosing sacroiliac joint-mediated pain was difficult because the presenting complaints were similar to other causes of back pain.  They also noted that radiographic and laboratory test primarily help exclude other sources of low back pain, while MRI, CT and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain.  The authors concluded that controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis.  All told, the documentation demonstrates the medical necessity of the sacroiliac joint injection and continued sacroiliac joint injections.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male enrollee has requested home health services for treatment of the enrollees dysphagia.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. In this case, the patient is stable on his current regimen of G-tube feedings and is doing well. His parent is able to administer the patients G-tube feedings without issues. Managing caloric intake or any formula changes could be performed on an outpatient basis. The clinical documentation submitted for review does not support the need for home health services to help with feedings. Parab and colleagues evaluated specialist home-based nursing services for children with acute and chronic illnesses. The authors concluded, Current research does not provide supporting evidence for a reduction in access to hospital services or a reduction in hospital readmission rate for children with acute and chronic illnesses using specialist home-based nursing services. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested continued residential treatment center (RTC) services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient meets the criteria for continued residential level of care. The patient has had moderate interference with addiction recovery efforts, moderate impairment in social functioning and a history that predicted destabilization without medium-intensity residential treatment as evidenced by 11 relapses in 12 months, within one week of discharge from each program. Based on the patients history, she needs intensive motivating strategies in a 24-hour program, as each time she has been discharged, she relapsed. Moreover, she is unable to interrupt a high severity or high frequency pattern of use and avoid dangerous consequences without 24-hour intervention. Finally, the patients home environment would not provide adequate support per the submitted documentation.  Thus, the patient meets the ASAM criteria for continued residential treatment provided from the date indicated forward. Based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested acute inpatient services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The medical records document a psychotic break indicative of the onset of a formal thought disorder, which as a class can be the most serious and debilitating of mental illnesses.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are preferred as they offer optimization of treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, discharge on the date indicated would not have been medically appropriate.  The patient was psychotic, and he was refusing medication.  To discharge a patient under these circumstances would have been inconsistent with current practice standards.  By the specified date, the patient was still symptomatic with poor insight.  His medications were well-tolerated but still being adjusted.  He remained engaged in active treatment that was reasonably expected to prevent a more serious episode of illness.  The current medical evidence supports the services at issue in this clinical setting.  All told, inpatient services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female has requested reimbursement for repeat EMG/NCV testing for the evaluation of chronic inflammatory demyelinating neuropathy.  Findings:  The physician reviewer found that the patient has an apparent diagnosis of CIDP. Electrodiagnostic testing is clinically appropriate in making the diagnosis of CIDP. Repeat electrodiagnostic testing has no proven role in the management of CIDP. No evidence was submitted that would support the need for the very extensive electrodiagnostic testing that was performed.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested for laparoscopic adjustable gastric banding and a Nissen fundoplication for treatment of the her obesity.  Findings:  The physician reviewer found that the National Institutes of Health (NIH) consensus guidelines do not consider GERD to be a life-threatening weight-related comorbid condition. Another condition such as diabetes, hypertension or sleep apnea is necessary in patients with a BMI of less than 40 to meet criteria of clinically severe obesity. In the case of this patient, there is no evidence a sleep study has been performed documenting obstructive sleep apnea and there is no medical note documenting sleep apnea outside of the consulting surgeons history and physical.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for carotid Doppler for evaluation of the enrollees left-sided carotid artery disease. Findings:  Two physician reviewers found that based on the records provided the patient presents with no documented neurologic symptoms, no documented focal neurologic deficits on physical examination, no documented carotid bruits, and no documented hemodynamically significant of greater than 50% stenosis on prior ultrasound. In this circumstance repeat yearly screening is not recommended and is not considered the standard of care in the medical community unless stenosis exceeds 50% or there is a clinical change such as new bruit or focal neurologic symptom. Even in this setting, the estimated risk of stroke attributable to an identified stenosis in patients with asymptomatic carotid atherosclerosis is very low at less than one percent annually. Final Result: The reviewers determined that the requested service is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional 2.5 hours per week (for a total 30 hours per week) of applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that Papatola and Lustig define medically necessary ABA services as (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Using this definition, ABA services are medically necessary for this patient. ABA therapy has been identified as the most evidence-based treatment for patients with autism, thus ABA is required to meet the essential health needs of the patient. To address the specific dosage of treatment, the Behavior Analyst Certification Board (BACB) support treatment recommendations made by a BCBA, as these providers have expertise and formal training in the provision of ABA for the treatment of autism. In this case, the patients BCBA recommended 30 hours per week of ABA services as clinically indicated for the treatment of this patients autism. This frequency of ABA services is consistent with Linstead and colleagues, who reported that there is a strong relationship between treatment intensity and mastery of learning objectives, where higher intensity predicted greater progress. Thus, lowering the patients ABA therapy hours could be detrimental to his continued skill development and safety. Given these findings, the requested additional 2.5 hours (for a total of 30 ABA therapy hours) per week 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 a licensed B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested physical therapy for the treatment of her neck and back injury. Findings:  The physician reviewer found that this patient continues to have neck and back pain secondary to trauma. Physical therapy is standard practice for the patient's injuries and resulting functional impairment. The specific interventions proposed by the physical therapist are appropriate for the patient's condition. Specific goals for the treatment sessions have been well-documented, and these goals appear obtainable in a reasonable and predictable period of time. Since the patient continues to respond and progress with the proposed treatments and failed an attempt at a home exercise program, additional skilled services by a physical therapist were and are medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of her hepatitis C virus.   Findings:  The physician reviewer found that according to the most recent guidelines issued, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-experienced genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for a minimum of 16 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. The guidelines reflect a medical trial, which showed higher efficacy with 16 rather than 12 weeks of treatment. The guidelines also cite data showing increased survival with earlier treatment. In this clinical setting, Sovaldi and ribavirin for 16 weeks is clinically indicated for the treatment of this patients hepatitis C infection. However, Sovaldi and ribavirin for 12 weeks is not supported as medically necessary.  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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Intracept procedure (procedure code 22899) and destruction of intraosseous basivertebral nerves (procedure codes C9752 and C9753). Truumees and colleagues reported significant improvement in pain and function in patients with vertebrogenic-related chronic low back pain treated with minimally invasive radio frequency ablation of the basivertebral nerve. Markman and colleagues noted an association between functional benefit from basivertebral nerve ablation and reduced opioid use. Fischgrund and colleagues found that patients with chronic low back pain treated with radiofrequency ablation of the basivertebral nerve in a randomized controlled trial exhibited sustained clinical benefits in the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) and maintained high responder rates at two years following treatment. The authors concluded that basivertebral nerve ablation appeared to be a durable, minimally invasive treatment for the relief of chronic low back pain. In this case, the requested service is an outpatient procedure that would allow to patient to avoid more invasive alternatives such as fusion and or artificial disc replacement while maintaining the structural integrity of the spine. Therefore, the requested Intracept procedure (procedure code 22899) and destruction of intraosseous basivertebral nerves (procedure codes C9752 and C9753) are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure (procedure code 22899) and destruction of intraosseous basivertebral nerves (procedure codes C9752 and C9753) are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a clinical chemistry test for treatment of the enrollees Crohns disease.  Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. The Prometheus Anser IFX Test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. There are few well controlled clinical trials to confirm that use of the Anser IFX test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. The clinical utility of measuring drug antibody concentrations is on a case-by-case basis, and based on the clinical documentation submitted for review, it has not been established how the patients management would change based on test results. In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, such as is this case. In sum, the measurement of antibodies to infliximab in patients receiving treatment with infliximab has not been established. Thus, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for evaluation 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  Two reviewers are board certified in gastroenterology and are 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

The patient has requested reimbursement for psychiatric residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient did not meet the criteria for psychiatric RTC services. The patients composite score is consistent with high intensity community based services. Given the lack of pharmacologic interventions and medical stability as well as lack of suicidality or safety concerns, the patient did not meet the requirements for medically monitored residence based services. Given these findings, the psychiatric RTC services not medically necessary for 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.