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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high dose rate (HDR) brachytherapy with Leipzig applicator for treatment of the enrollees basal cell carcinoma. Findings:  The 3 physician reviewer found that Basal cell carcinoma is a non-melanoma skin cancer which develops in response to long-term sun exposure. The standard of care for basal cell carcinoma on the nasal tip is considered to be Mohs micrographic surgery for margin control. The use of brachytherapy is not considered to be standard of care for the treatment of basal cell carcinoma on the nasal tip. The National Comprehensive Cancer Network (NCCN) guidelines state that there is insufficient long-term efficacy and safety data to support the routine use of electronic surface brachytherapy. Given that the requested treatment is not considered to be standard of care and NCCN guidelines do not recommend its use, the requested HDR brachytherapy with Leipzig applicator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in radiation oncology 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 50-year-old female enrollee has requested a computed tomography (CT) scan for evaluation of her left foot pain.  Findings:  The physician reviewer found that the patients records discuss a negative MRI of the affected foot in the past, but no report is included for review. An MRI is the procedure of choice for the evaluation of stress fracture, tendinopathy, tenosynovitis, or reactive changes of degenerative joint disease. Accordingly, the records do not support the medical necessity of a CT of the foot and ankle absent any abnormality reported on the prior MRI. By contrast, CT imaging would be useful for the evaluation of fracture fragments, characterization of degenerative joint disease, or even erosive arthritis, but there is no mention in the records to suggest these as clinical possibilities. Thus, the requested CT of the foot and ankle is not medically necessary for further evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested residential eating disorder services for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the patient achieved a weight that is medically stable and is appropriate for functioning on an outpatient basis. Concurrently her medical condition stabilized and she no longer required 24-hour care and supervision as of the said date.  The major contention for keeping her at the residential level of care is the need for motivational enhancement, however this is not a criteria for 24-hour level of care and such motivational enhancement can be provided at a lower level of care.  All told, the patients eating disorder had stabilized as of the date in question and she was appropriate for discharge to a less intensive level of care as of that date. Thus, the residential eating disorder treatment services provided from the timeframe noted were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient hospital stay for treatment of his bladder tumor. Findings: The physician reviewer found that noted in the medical literature, the majority of patients who undergo transurethral resection of bladder tumor can be discharged either on an ambulatory basis or within 24-hours of the procedure. This patients procedure was an elective, scheduled procedure. The patient did not have any significant risk factors which would have increased the risk of post-operative complications. His post-operative course was essentially normal without any significant complications other than minor issues with pain control. Observation status for this patients clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Thus, the inpatient hospital stay was not medically necessary for treatment of this patients bladder cancer. 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 urology 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 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, the residential treatment center services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review indicate that the patient appeared to have reached a baseline status, and there was no reasonable expectation that condition would further improve with continue treatment with residential care. There was no evidence that he was suicidal, homicidal, or had self-injurious behaviors to the point of requiring medical care. Throughout the course of treatment there were minor incidents of self-injurious behavior, but none that required medical intervention or medical consultation. He had long-standing behavioral issues but these did not warrant residential treatment and could have been treated at a lower level of care. Therefore, the patient could have continued treatment at a lower level of 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: Medical Necessity
Decision: Upheld

 Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested occupational therapy for treatment of the enrollees autism spectrum disorder.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. While the literature indicates occupational therapy can help improve fine motor skills, in this case, the patient presents with sufficient fine motor skills per PDMS testing. The patients primary deficits involve issues of self-regulation and following adult directions which are symptoms of autism. As such, the Health Plans recommendation that the patient collaborate with the patients ABA provider is medically reasonable and appropriate to address his adaptive skills, social skills and self-regulation. Based upon the documentation provided, the medical necessity of occupational therapy has not been established.  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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 the ReWalk Exoskeleton System/durable medical equipment (DME) (HCPC: E1399)  one unit. Findings:  Three physician reviewers found that the proposed equipment is not an efficient, reliable or practical means of mobility for persons with paraplegia in comparison to standard mobility devices such as manual wheelchairs. Recent evidence suggests that these type of exoskeletal ambulation devices have high feasibility challenges and have not met users high expectations of benefits. There is no expected significant health benefit of passive walking using an externally powered exoskeleton to power the lower limbs. In this clinical setting, the standard of care is employing appropriate pressure relieving maneuvers using volitionally intact musculature, and promoting physical activity using volitionally active musculature, including regular propulsion of a manual wheelchair, wheelchair sports and other adaptive sports/exercise activities. Compared to these standard activities, the physical activity promoted by powered exoskeleton-aided ambulation is modest. The benefits of the proposed device with respect to health and mobility in the setting of the patients medical condition have not been established.  The available, published data are scarce and low quality. Moreover, there is a risk of injuries, especially if it is used outside of a controlled environment like a physical therapy gym. Thus, the ReWalk Exoskeleton System/DME (HCPC: E1399)  one unit is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested equipment is 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 number one and three are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer number two is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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: Overturned

The patient has requested reimbursement and prospective authorization and coverage for twice-weekly nutritional therapy services. Anorexia nervosa is one of the most difficult psychiatric disorders to treat. Patients with this disorder are generally resistant to treatment and are ambivalent about therapy. Given how difficult it is for patients with anorexia to engage in treatment, this patients trust and rapport with her current therapist and motivation to continue treatment are highly positive predictors of success. Training and experience in nutrition therapy specific to eating disorders promote a positive outcome in patients (Reiter and Graves). The physician reviewer found American Psychiatric Association (APA) recommends that normalization of nutrition and eating habits is a central goal in the treatment of patients with bulimia nervosa. Since this patient has failed prior treatment at the RTC and PHP levels of care but has demonstrated commitment and improvement with nutritional therapy, she is likely to continue to benefit with this modality. Therefore, twice-weekly nutritional therapy services provided were and are medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for eight hours of neuropsychological testing. Formal neuropsychological testing entails the use of assessments with normative values that can account for gender and a wide range of ages and educational backgrounds, and can distinguish between the causes of cognitive impairment. Neuropsychological testing can last up to several hours, oftentimes divided across multiple visits. By determining the etiology of a patients cognitive problems, this testing can help guide treatment as well as medical management. If her cognitive complaints are due to depression or anxiety, medication changes can alleviate these symptoms. However, if her symptoms are due to chronic drug exposure and learning disabilities, her provider may avoid medication changes. In this limited clinical instance, complete neuropsychological testing is indicated to help determine the patients diagnosis and appropriate medical management. All told, the requested eight hours of neuropsychological testing is medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Suboxone for treatment of the enrollees chronic back pain. Findings: The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  The use of buprenorphine (Suboxone) for management of chronic pain is supported by peer-reviewed literature (Roux et al; Malinoff et al).  In this patients case, he has been stable on the Suboxone dose and has an ongoing opiate maintenance agreement in place.  Although the patient is not in an ongoing psychological program, it is not consistent with good medical practice to discontinue Suboxone on that basis.  While psychological counseling has a place to support ongoing detoxification and maintenance, its role in ongoing pain management is not an absolute requirement.  This patient has been stable on his current medication regimen.  All told, Suboxone is medically indicated 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 anesthesiology with sub-specialty certification in pain 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

This patient is a 16-year-old male diagnosed with dysthymic disorder, oppositional defiant disorder, ADHD, and marijuana abuse who was admitted to residential treatment after nine weeks in a wilderness camp setting. He was described as verbally defiant with his parents, inclusive of spending up to 12 hours per day playing violent video games, staying up late and then sleeping in, faring poorly in school, and having a constantly argumentative stance. In one instance when most defiant, he reportedly pulled a knife on his mother.  At the time of admission to residential treatment, neither he nor his family were involved in outpatient treatment. Chart notes describe the patient as afflicted with the aforementioned diagnoses, supported by formal testing, but also include an assessment of pronounced narcissism. Family dynamics were also of relevance as the parents differed in their approach to the patient and the patient took full advantage of the parental discord in that regard. One particularly telling note describes the patient as compliant and cooperative in the therapeutic environment but goes on to say that much of the problem lies in the family dynamic. Patient tends to want to argue and manipulate to get his way. Sees no need to have structure at home. The parents have reinforced this behavior by allowing him to escape responsibility and giving in to the pressure that he puts on them to get his way. The patient was not a management problem while in residential treatment.  He was treated with a variety of psychotherapies but received no medications. The patient ultimately left the facility against medical advice.  The Health Plan denied the fathers request for reimbursement for the services based upon their determination that they were not medically necessary.The fact that the patient did not appear to be a management problem while in the residential treatment milieu is not particularly surprising given that the primary arena of conflict was with his parents. He was portrayed as narcissistic, but not inordinately difficult to handle. A trial of partial hospitalization could reasonably have been attempted prior to residential treatment. Similarly, given the disunity in the parents approach to the patient, and the patients efforts to split them when the opportunity presented, family therapy was obviously indicated and could have occurred on an outpatient basis. In fact, had the patient remained at home with his parents, the impetus for successful family therapy may have been greater. Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for anesthesia services (CPT code 00811QZ) provided during a colonoscopy. The American Society of Anesthesiologists (ASA) guidelines for sedation and anesthesia in gastrointestinal (GI) endoscopy recommend anesthesia provider-administered sedation for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. In addition, minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. A review by Wernli and colleagues concluded that the use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. In this case, the patient does not have significant comorbid health conditions and had a pre-procedure ASA score of 2. The patients airway was a Class II Mallampati score presenting for a colonoscopy. The physician reviewer found that documentation of a previous personal or family history documenting problems with anesthesia or with colonoscopy to suggest the need for MAC services. Overall, the current ASA guidelines do not support the use of MAC and propofol sedation a patient who does not have significant health conditions or airway concerns. The guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, which was the case with this patients procedure. The review by Wernli and colleagues concluded that the use of anesthesia services in low-risk patients, such as this patient, was associated with increased complications. Based on the available information provided for review, the anesthesia services (CPT code 00811QZ) provided during a colonoscopy were not medically necessary for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  A patient is requesting reimbursement for MTHFR mutation genetic testing that was provided due to a diagnosis of colorectal cancer. The providers letter of medical necessity states that Methylenetetrahydrofolate Reductase (MTHFR) mutation testing was performed for screening diagnosis and clinical management. The Health Plan has denied the requested reimbursement for this procedure and reported that the procedure is investigational and not medically necessary for the enrollees medical condition.Findings:  Three physician reviewers found that National Comprehensive Cancer Network (NCCN) Guidelines for colon and rectal cancers do not support testing for methylenetetrahydrofolate reductase (MTHFR). Support from observational studies for folate as a factor in cancer protection have shown that lower levels of MTHFR, an enzyme involved in folate metabolism, have a reduced risk of colon cancer. In this case, however, the patient already has advanced colorectal cancer and it is unclear how testing would change her management. Under these circumstances, MTHFR Genetic Testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested MTHFR Genetic Testing provided 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: Physician reviewers 1 and 2 are board certified in internal medicine with a subspecialty certification in medical oncology and physician reviewer 3 is board certified in internal medicine with a subspecialty certification in medical oncology and hematology and are all three 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.