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

A 58-year-old female enrollee has requested physical therapy (PT) sessions for treatment of her right shoulder status post arthroscopic rotator cuff repair surgery. Findings:  The physician reviewer found that it is often necessary to continue stretching, exercises and modalities for a prolonged period of time after rotator cuff repair surgery, especially following open repair of severe tendon tears. These exercises and treatments, however, do not necessarily require a formal outpatient setting indefinitely.  Diverse types of shoulder dysfunction demonstrated improvement in both clinical and functional measures at the conclusion of physical therapy, although it is not possible to determine whether these changes were due to the interventions or due to time(Millar and colleagues). Similarly, in 2010, Seida and colleagues commented on the paucity of publications in support for PT in the management of patients following rotator cuff injury, concluding that, Evidence on the comparative effectiveness and harms of various operative and non-operative treatments for rotator cuff tears is limited and inconclusive. Overall, the clinical necessity of long-term formal PT for this patients condition has not been established in the scientific data. In the present case, the patient underwent an arthroscopic right rotator cuff repair on the said date. A few months later, the patient had attended 20 PT visits and should have been well versed in a self-directed exercise and modality program. She had functional ROM and good to good plus strength. There were no indications that she was not independent with her activities of daily living (ADLs) and further gains in strength and ROM could have been gained through an independent program. Notably, the records suggest the patient had plateaued after the said date, with 155 degrees of active flexion and 50-55 degrees of active external rotation. There is no documentation of therapeutic or passive exercises that required ongoing supervision or that could not have been substituted with independently performed exercises. As such, no significant difference in functional outcome would have been expected with ongoing passive modalities and manual therapy in the formal setting as of the date in question. Thus, the services at issue have not been shown to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee has requested reimbursement for residential treatment services for treatment of her alcohol dependence. Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting.  In general, modern psychiatric practice aims to provide care at the least restrictive setting that is likely to effectively address the issues driving the symptom complex or pathological behaviors which cause functional impairment.  In this patients case, residential treatment was recommended on the date indicated as the patients alcohol use was dominating all functional domains.  Despite living at home with a supportive family, her ambivalence, living environment and social supports were not conducive to sobriety.  Her longitudinal history, psychosocial situation, and severity of symptoms including concerning toxic serum alcohol levels and evidence of hepatic distress justified specialized treatment in a structured, 24-hour supervised setting as a less restrictive setting was likely to be ineffective.  Residential treatment was reasonably expected to improve her condition and prevent a more serious illness.  All told, residential treatment services provided from the specified timeframe were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old male enrollee has requested Botox for treatment of his neck and shoulder pain.  Findings:  Two physician reviewers found that Botox is an accepted treatment for neuromuscular conditions such as torticollis, but is considered experimental for trigger points and muscle spasms despite the obvious contradiction. The evidence in this case indicates the patient has failed to respond to several of the more standard therapeutic modalities, but has achieved symptom relief with Botox treatments. Subjectively he is pain free and objectively he no longer requires trigger point injections or narcotic pain medications.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Based on the records provided, this patient presented with some coronary risk.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.   These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), myeloperoxidase, sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Thus, advanced lipoprotein testing performed was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: All three reviewers 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 patient has requested authorization and coverage for Synvisc injection to the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this patients case, the options are limited. The patient has tried and failed other conservative treatments including non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections, with the alternative being a total knee arthroplasty. All told, the requested Synvisc injection to the left knee 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested weekly occupational therapy for medical treatment of the enrollees oral motor skills delay.  Findings:  The physician reviewer found this patient cannot swallow solids which will significantly impair his nutrition and his inability to be fed outside of the home, such as at school. Schwarz and colleagues reports that successful treatment of a feeding disorder results in improved energy consumption, nutritional status, and reduced hospitalizations. The occupational therapists notes document modest improvement, but not successful nutrition. In sum, it is medically necessary that this patient continue with weekly occupational therapy. Therefore, the requested weekly occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 24-year-old male enrollee has requested dental implants for the treatment of the enrollees cleft lip/palate and congenital malformation due to root resorption. Findings:  The physician reviewer found that patients with facial clefting present many challenges. The goal of treatment is to provide normal function and esthetic appearance. The optimal management of patients with cleft lip and palate is usually done under the direction of a multidisciplinary team in order to achieve satisfactory results. Treatment can often last into the patients late teenage years to early twenties. Specific therapeutic goals for maxillofacial deformities include improving mastication/swallowing, improving occlusion and improving dental and periodontal health. Given that the patient had a congenitally missing #7 as well as malformed ##8-10, dental implant placement in order to reconstruct his anterior maxilla was necessary in order to achieve the therapeutic goals for this patient with cleft lip and palate. In addition, reconstructive surgeries performed to correct deformities caused by congenital or developmental abnormalities for the purpose of improving bodily function or symptomatology or creating a normal appearance is a covered benefit per the coverage of benefits which was provided.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male has requested sensory integration occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that the patient is significantly impaired, as he is diagnosed with autism, cognitive delays, has limited vision, epilepsy, and cerebral palsy.  When he was assessed by the Plans occupational therapist, he was noted to be difficult to test as he had trouble modulating his responses and overreacted to external stimuli. Sensory integration occupational therapy is a therapeutic approach to modify such over-reactive phenomena. It would be the customary medical practice of community-based child neurologists to refer this developmentally delayed patient for sensory integration occupational therapy. Occupational therapy involving sensory integration techniques (OT) attempts to improve the patients abilities to adapt and function in activities of daily living. Given this patients degree of sensory processing and motor impairment he has a medical necessity for OT services. Schaaf and Miller performed a study and conclude that sensory integration techniques enabled occupational therapists to assist the developmentally delayed child in developing the ability to integrate into normal motor and personal-social patterns and to function with his peers. In a well controlled study by Miller, et al., the authors reported significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children.  Further, Roberts and colleagues describe improvement of behavior patterns in children who have been treated with OT utilizing sensory integration techniques. Based on the documentation provided for review and the data available in the peer reviewed medical literature, it is medically necessary that this patient receive the requested sensory integration occupational therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Coflex interlaminar stabilization device. This patient presents with progressively worsening and severe low back pain radiating into the lower extremities, left greater than right, with signs and symptoms of neurogenic claudication. He has associated significant functional limitations that interfere with activities of daily living. He is status post prior anterior lumbar interbody fusion at the L5-S1 level. He has failed to improve despite conservative treatment. The neurosurgeon has recommended decompression and stabilization surgery using the Coflex device over an instrumented fusion at the L4-L5 level adjacent to the prior fusion. The current evidence-based literature and long-term studies support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis at one to two levels. Therefore, the requested Coflex interlaminar stabilization device is likely to be more effective than other treatment options. Findings:  Three physician reviewers found the requested device is 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. Final Result: The reviewers determined that the requested device is 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

A 43-year-old male enrollee has requested Avastin for the treatment of his glioblastoma. Findings:  Three physician reviewers found that the literature on the use of Avastin in gliomas is compelling and there is evidence of activity noted. However, there is no evidence to support retreatment with Avastin after progression, nor is there any data on its safety in this situation. Given the patients progression while on the drug, there is no clinical indication to re-administer it at this time. Per NCCN guidelines, there are reasonable alternatives available in this setting, such as platinum-based therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested  coverage for proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that the patient has a T2a, Gleason 6 (3+3), PSA 2.0 prostate cancer. According to the Partin tables, there is an 18% probability his tumor is confined to the prostate, a 17% probability of capsular involvement and a 1% probability of seminal vesicle involvement; there is no pelvic lymph node involvement (N0).  Treatment options including conventional radiation therapy, permanent seed brachytherapy, temporary HDR, hormonal therapy and IMRT have been reviewed with the patient. Based on the clinical data and the Partin table analysis, I would agree with the assessment of the radiation oncologist that the patient has a very small volume of tumor and the conventional treatment modalities discussed previously are clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested continued skilled nursing facility services for the treatment of his scleroderma. Findings:  The physician reviewer found that the medical necessity of continued skilled nursing facility services has not been demonstrated. This patient was admitted to skilled care and made documented functional gains. He is now able to transfer with minimum assistance to stand-by assistance. The progress notes do not demonstrate further skilled needs. The patient has multiple chronic conditions. He is currently stable and does not require skilled nursing care. With regard to his participation in rehabilitation, the level of therapy and degree of impairment are such that informal in-home therapies would be sufficient. Continued skilled nursing facility services are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested substance abuse residential treatment for treatment of his amphetamine dependence. Findings:  The physician reviewer found that this patient had no history of any type of intensive treatment for substance abuse.  Although he complained of job problems, there is no report of him losing his job due to use.  He had no legal problems due to his use either.  The medical notes mentioned a history of depression, but he was not placed on any psychiatric medications during his stay. In cases such as this, an evidence-based instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is useful in determining the necessary level of care to ensure the level of care meets individual needs safely and effectively, in the least restrictive setting possible. Applying these guidelines, the patients risk of harm was low, functional status could be classified as mild, medical, addictive and psychiatric comorbidity was significant, recovery environment was supportive, treatment and recovery history was equivocal and engagement and recovery status was positive. Per these guidelines, high-intensity community-based services were indicated.  Per the American Psychiatric Association guidelines, criteria for placement in a residential treatment center includes: (1) When the patient does not meet the clinical criteria for hospitalization but his life and social interactions have come to focus predominantly on substance use; (2) The patient lacks sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting; (3) The patient demonstrates denial that could respond to interpersonal and group confrontation.  Since this patient was able to hold a job, his functional level remained adequate.  Most individuals have some degree of job performance issues when they abuse substances. However, this patients job performance issues appear milder in the spectrum of dysfunction. Therefore, the first two criteria do not apply to him.  Thus, he does not meet criteria according to the American Psychiatric Association guidelines for residential treatment services. All told, substance abuse residential treatment provided during the time period at issue was not medically indicated. This patient could have been treated safely and effectively at a less restrictive setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for subacute inpatient skilled services. Anoxic brain injury, including due to cerebral hypoperfusion during cardiac arrest, is a condition with a challenging clinical course and guarded outcomes. Smania and colleagues report that while functional and cognitive impairments in patients with severe traumatic, cerebrovascular, or anoxic acquired brain injury may improve with time and rehabilitation, patients with cerebrovascular and anoxic acquired brain injury may have a more challenging clinical course. In this case, the patient sustained a severe anoxic brain injury following cardiac arrest. The records do not document any indication of clinically significant cognitive recovery. The patient has not been able to actively participate meaningfully in rehabilitation interventions to date and is not expected at this time to be able to participate in therapies going forward. Overall, the patient has a poor prognosis for functional recovery and has required total care on an ongoing basis since the event.  Given that the patients care needs require custodial level of care and as the patient has stabilized with respect to his care needs, including his tracheostomy care, supplemental oxygenation needs via tracheostomy collar/mask, tube feeding, skin care, and bowel/bladder care, the services at issue were not and are not medically indicated. Therefore, subacute inpatient skilled services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested for a Meniett device for Menieres disease for treatment of his Menieres disease. Findings:  Two physician reviewers found that the nature of Meniere's disease, with a highly variable clinical presentation, lack of pattern or often a provoking reason for the attacks makes management difficult. The pathology is understood as an increase in pressure in the fluids of the inner ear, but the cause of that pressure increase is not known. Over the years various treatments, medical and surgical have come and gone. Most of them boast small studies with limited results suggesting a breakthrough, but many have subsequently been abandoned as more data is gathered. An interesting feature of many of these studies is a significant improvement in symptoms in placebo groups, regardless of the treatment studied.The Meniett device invokes a theory that by increasing air pressure in the middle ear, fluid in the inner ear will be displaced and Menieres symptoms will reduce. Early studies often (though not always) show some benefit in the treated groups in reduction of dizziness, but objective criteria such as the hearing loss that accompanies Menieres disease remains unimproved.