Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee requested genotype testing (CPT codes 81226, 81225, and 81281) for medical  evaluation of the enrollees major depressive disorder, panic disorder, and generalized anxiety disorder.   Findings:  Three physician reviewers found that the American Psychiatric Association (APA) suggests that more research is needed before genetic testing can be recommended for routine clinical use.   Regarding this particular clinical scenario, significant case-specific psychosocial issues were referenced. Such external stressors typically do not respond to pharmacological interventions and this may help explain this patients suboptimal response to medications. Additionally, there was no mention of any community-based interventions. Although psychodynamic and cognitive behavioral therapies were noted in the psychiatry documentation, there was no mention of treatment trials from other therapists or in alternative levels of care, such as an intensive outpatient or partial hospital program.  Further, there was no comprehensive treatment plan or validated rating scales to judge the effectiveness of the therapeutic interventions.  Thus, genotype testing (CPT codes 81226, 81225, and 81281) was not likely to have been more beneficial in this patients evaluation and treatment than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a seven-year-old male enrollee have requested speech therapy services for the treatment of the enrollees mildly delayed expressive language disorder. Findings:  The physician reviewer found that the records provided demonstrate a clear diagnosis of expressive language delay as well as semantic and syntax problems. The therapy program instituted was reasonable and within the standard of care. The patient clearly had a condition that would benefit from speech therapy. The therapy provided was, in fact, beneficial for this patient. All the information submitted demonstrates that this patient was an appropriate candidate who received an appropriate course of indicated speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Dexcom continuous glucose monitor for treatment of his medical condition.  The physician reviewer found that the Dexcom continuous glucose monitor is medically necessary for treatment of the patients medical condition. In this case, the patient has been managing his diabetes mellitus type 1 with the assistance of continuous glucose monitoring system, Dexcom. He has been adherent to real time self-management, hence his HbA1c is at target and he has not had harmful hypoglycemic events or severe hyperglycemia. That is exactly how continuous glucose monitoring must be used. In addition, the peer-reviewed literature cited above demonstrates continuous glucose monitor efficacy in improving diabetes control in a sustained way. In sum, the Dexcom continuous glucose monitor is medically necessary for this patient to continue his diabetes management and control at target levels without wide fluctuations and hypoglycemic events. 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 diabetes, metabolism and endocrinology 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 Trulicity (dulaglutide). Findings:  The physician reviewer found that Trujillo reports that glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as Trulicity, have been incorporated into type 2 diabetes clinical guidelines. GLP1 RAs promote glucose control through mimicking GLP1 and activating GLP1 receptor mechanisms, thus increasing glucosedependent insulin secretion, inhibiting glucagon secretion, and decreasing gastric emptying. Iorga and colleagues note that GLP1 RAs associated with a significant reduction of cardiovascular and all-cause mortality. Given that current medical literature supports the use of GLP-1 RAs to improve glycemic control and aid weight loss, and as carrying a lower risk of hypoglycemia compared with other glucoselowering treatments, the requested medication is medically indicated. Therefore, Trulicity (dulaglutide) is medically necessary for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional acupuncture services for treatment of the enrollees thoracic pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The patient has a history of chronic thoracic pain, shoulder pain and headache. The patient presented with reports of improved pain after his first acupuncture treatment. The patient presented with thoracic pain, shoulder pain and headache. The patient rated his pain at 3-4/10, stating that he felt better after the last acupuncture treatment. After the initial six acupuncture sessions, an additional acupuncture six sessions were authorized. The patient was then authorized for two more acupuncture visits. The acupuncture received by the patient have failed to demonstrate significant pain score changes, and measurable functional improvements in activities of daily living. Based on the lack of significant, measurable gains obtained with prior acupuncture, the request for additional acupuncture services are not medically necessary for treatment of the patients medical condition. 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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old female who is requesting a total knee replacement. The patient apparently injured her knee in 1996 and continues to have pain. X-rays do not reveal significant arthritis in the knee. The patients provider does not believe the patient is a candidate for total knee replacement.With regard to total knee replacement, the patient is considered very young. An indication for total knee replacement is severe arthritis. This patient does not have significant arthritis in the knee. As such, there is no medical indication for this patient to undergo total knee replacement. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for brain magnetic resonance imaging (MRI) (CPT 70553), and/or head magnetic resonance angiography (MRA) (CPT 70546), and/or neck MRA (CPT 70549). Diplopia is a common symptom identified in ophthalmological and neurological patients with multiple underlying causes. The onset of diplopia is most often sudden, but it can also be gradual, determined by trauma, or spontaneous. While the acute onset is more suggestive of a vascular event but is not specific, the gradual progression or diplopia that has changed the pattern is more indicative of a compressive lesion (Iliescu, et al.). In the diagnosis and management of transient ischemic attack and stroke, imaging of the brain and intracranial and extracranial blood vessels is an important part of the diagnostic assessment. Brain evaluation using MRI is a sensitive way of assessing for brain ischemia (Coutts). In this case, the patient presented with acute and recurrent episodes of diplopia and visual disturbance and has a history of hypertension and hyperlipidemia. As noted in the medical literature, diplopia can be caused by ischemia or stroke. MRI of the brain and MRA of the head and neck have been shown to be important diagnostic modalities in the assessment of patients with when there is concern for transient ischemic attack or stroke. Given this support, the brain MRI (CPT 70553), head MRA (CPT 70546), and neck MRA (CPT 70549) were medically necessary for this patient.Final Result: The reviewer determined that the services at issue were 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested behavioral analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that the submitted documentation establishes the medical necessity of the services at issue. Reichow and colleagues reviewed the evidence for the effectiveness of early intensive behavioral intervention (EIBI) in increasing the functional behaviors and skills of children with autism. The authors reported improvements in cognitive skills, adaptive skills and communication with this type of treatment. Mohammadzaheri and colleagues noted that ABA is helpful for school children with autism spectrum disorders for aggressive, disruptive and tantrum behaviors. In this case, the patient has been making progress. There is a lack of evidence that this patient has maximized progress. Thus, ABA services at the frequency of 40 hours per week of ABA therapy and supervision is medically necessary for treatment of the patients maladaptive behaviors.  Final Result: Two reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is actively practicing and is board certified in pediatrics and child neurology. Physician reviewer number two is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics. Physician reviewer number three is actively practicing and is board certified in child neurology.  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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a Diagnostic Audiologic & (Central) Auditory Processing Evaluation. Findings:  The physician reviewer found that Auditory processing disorder (APD) is a well-recognized condition. The condition is associated with reading, language, and reading disorders. It is also associated with other conditions such as attention deficit hyperactivity disorder (ADHD), developmental language disorders, and reading disorders (Bailey, T.). Abnormal auditory testing results seen in children diagnosed with central auditory processing disorder (CAPD) are most commonly due to attentional problems (Moore, D., et al.). Children with attention deficit hyperactivity disorder (ADHD) can be diagnosed with CAPD because of their difficulties with attention and focus, which are due to the underlying disorder and not to a separate auditory processing problem. In this case, the patient is suffering from some spelling difficulty and inattention at home and school. The patients mother has expressed concern about the patients auditory processing disorder and wanted CAPD testing. The patient was seen and was thought to have ADHD, and a referral to an ADHD clinic was made. If the patient is evaluated for ADHD and is not found to have ADHD, then CAPD testing and treatment is warranted. At this point, however, CAPD testing is premature and not medically necessary. Accordingly, the requested Diagnostic Audiologic & (Central) Auditory Processing Evaluation is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 for residential treatment center services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the submitted documentation supports the services at issue for this patient. Standard practice regarding treatment referrals usually progress in a step-wise fashion from less to more restrictive settings; however, episodically bypassing intermediate levels of care may often be clinically appropriate. Relating these general concepts to this particular dispute, this combat veteran had co-occurring alcoholism and mental illness. The patient had recently endured two dramatic work-related violent events that exacerbated his symptom complex. The diagnosis of PTSD is characterized by a pathological inability to feel safe, and these events, occurring within the patients social network and place of employment, served to fortify the distorted cognitive schemas that fuel the impairment of the condition.  Despite a supportive family, prior residential treatment and a sober living residence, he was consuming excessive alcohol.  He was having social impairment, medical sequelae and intrapsychic distress due to his drinking.  Moreover, the patients depression and PTSD were significant, yet untreated.  On presentation, the patient was anxious, labile and depressed.  During his admission, the patient has received evidence-based treatment and aggressive pharmacotherapy aimed at addressing the patients convoluted relationship with alcohol and mobilizing the meaningful therapeutic momentum needed to foster sustained sobriety. Although the patient had not engaged treatment in a less restrictive setting during the episode of illness, considering the confluence of biological and psychosocial factors, treatment at a setting less intensive than residential would be inadequate at this time. The comprehensive services being provided have been delivered in accordance with an individual treatment plan.  They address not only his addictive illness, but his anxiety and depression as well.  Further, the services remain reasonably expected and medically necessary to improve the patients condition and prevent a more serious episode of illness.  Considering the clinical presentation and perusal of the peer-reviewed literature, residential placement is a safe, appropriate disposition consistent with good medical practice. Accordingly, the services at issue were and are medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were and 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 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 thirty-four year-old male with diagnosed Bipolar Disorder is requesting authorization for residential treatment services.  Reviewers Findings:  The reviewing physician found that the extent of the patients illness warranted inpatient treatment.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old woman who was diagnosed with mild to moderate sleep apnea in August 1994 with a respiratory disturbance index (RDI) of 32.5 events per hour.  The patient indicates she has used CPAP with nasal pillows since that time.  A follow-up sleep study was completed in August 2005. The patient believes the results of the study were inaccurate. She has requested authorization for replacement supplies for her CPAP machine. Based on the results of the August 2005 study, the Health Plan has determined CPAP therapy is not medically necessary.The patient has a documented history of obstructive sleep apnea and associated symptomatology. She was started on CPAP therapy with good results. It is medically reasonable and appropriate to continue this treatment, which has proven effective for the patient in the past.  As such, the requested CPAP supplies are medically warranted and should be authorized. Accordingly, I have determined the requested supplies are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for in-home setting for the enrollees authorized physical therapy (two visits per week), occupational therapy (two visits per week), and speech therapy (two visits per week). The records provided for review document that this patient has a history of Down syndrome and aspiration. The patient has been treated with occupational, physical, and speech therapies, with documented progress. The patients current treatment regimen is consistent with the recommendations from the National Down Syndrome Society. The patients provider has recommended in-home therapy services. Currently, the patient is too young to be immunized for COVID-19. Repeated visits out of the home for therapy during the pandemic markedly increase her risk for exposure to infection. Vita and colleagues noted that, Down Syndrome, which is caused by trisomy 21, is characterized by immune dysregulation, anatomical differences in the upper respiratory tract and higher rate of comorbidities. All these risk factors can contribute to more severe clinical presentations of COVID-19 in this population. Similarly, Espinosa reported that the immune dysregulation caused by trisomy 21 in patients with Down syndrome supports additional monitoring and specialized care for this vulnerable population. All told, the requested in-home setting for the patients authorized physical therapy (two visits per week), occupational therapy (two visits per week), and speech therapy (two visits per week) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the continuous passive motion (CPM) for treatment of the enrollees right hip pain.  Findings:  The physician reviewer found that according to the current medical literature, the CPM device provided to this patient was not medically necessary. Given the outpatient nature of the patients treatment, the standard of care would be for the patient to start outpatient physical therapy. The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a specific protocol of rehabilitation following hip arthroscopy or any other hip procedure. Thus, the CPM provided was not medically necessary for treatment of this patients right hip pain.  Final Result: The reviewer determined that the device at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.