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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for anterior lumbar interbody fusion (ALIF) spine surgery and a one day hospital stay. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees low back pain.  Findings: There is support in the medical literature for the medical necessity of the requested services in this clinical setting. ALIF is indicated for advanced degenerative disc disease of the lumbar spine and has a high success rate in these cases. Furthermore, it is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone ALIF has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft. Based on these guidelines, the requested ALIF procedure is appropriate for treatment of the patients severe degenerative disc disease that has not responded to non-operative treatment.  As such, ALIF spine surgery and one day hospital stay are medically necessary for treatment of this patients medical condition.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: Experimental/Investigational
Decision: Overturned

A 46-year-old male enrollee has requested the Zio Patch for evaluation of his history of intermittent dizziness, pre-syncope and syncope. Findings:  Two physician reviewers found that the device at issue was likely to have been more effective than other modalities for evaluating this patient.  External ambulatory event monitors are used successfully in many clinical circumstances to diagnose, risk stratify and ultimately treat patients with a variety of complaints thought to be secondary to cardiac arrhythmias.  There is adequate support for the device at issue in this clinical setting.  Rosenberg and colleagues compared the Zio Patch to 24-hour Holter monitor in 74 patients with paroxysmal atrial fibrillation.  The authors noted that the Zio Patch allowed for longer continuous monitoring than a Holter monitor, resulting in improved clinical accuracy.  In sum, the Zio Patch was likely to have been of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested transportation by air ambulance for the treatment of his medical condition. Findings:  The physician reviewer found that there was no documentation provided necessitating transfer by air ambulance to another hospital. There were no specific recommendations made by the patients physician team indicating that the hospital requested by the patient was the only facility in the area that could meet his requirements for rehabilitation care. The recommendation was for a rehabilitation facility with expertise in spinal cord injuries. The patient was accepted by a facility that did not require transfer by air ambulance. Per Medicare guidelines, which are consistent with the standard of care in this setting, air ambulance transfer is only considered medically necessary if the patient is transferred to the closest hospital that can medically treat the patient and if ground transport would jeopardize the health of the patient. The submitted evidence does not establish that the hospital requested by the patient was the closest hospital that could medically treat him. Nor is there clinical evidence demonstrating this patient required air ambulance transport for a specific medical indication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar spinal fusion for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Evidence-based medical guidelines and peer-reviewed criteria have been met. This patient presents with persistent and worsening low back pain with radiculopathy. Significant functional difficulty is documented. Clinical examination findings are consistent with imaging evidence.  Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted.  There is discussion and imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, the requested lumbar spinal fusion is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for treatment of the enrollees paranasal sinus cancer.  Findings: Two physician reviewers found that the use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability.  Certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies, are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for sinonasal cancers as well, and proton therapy is an accepted treatment modality.  In general, proton therapy is more effective in sparing the normal tissues in and around the base of skull.  When these critical structures are in the target volume, proton therapy is often the only manner in which to safely treat the target.  In this patients case, there is documentation that intensity modulated radiation therapy would have resulted in an unacceptable plan given the location of disease.  There is sufficient support for the services at issue in this clinical setting.  All told, proton beam radiation therapy was likely to have been superior over other treatment options.Final Result: Two reviewers determined that the services at issue were 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: All three physician reviewers are board certified in radiation oncology 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: Upheld

A 55-year-old female enrollee requested facet joint injections, CPT codes 64490 x 2, 64491 x 2, and 64492 x 2 for medical treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested facet joint injections in this clinical setting.  In this patients case, physical examination did not indicate whether her pain was derived from the facets.  Additionally, there was a lack of imaging studies demonstrating facet pathology.  Based upon review of the clinical notes, there is a lack of documentation indicating that the patient has tried and failed conservative therapy, including physical therapy.  All told, the requested facet joint injections, CPT codes 64490 x 2, 64491 x 2, and 64492 x 2 are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested a power wheelchair for treatment of her degenerative disc disease.  Findings:  The physician reviewer found that the records indicate that the patient has some mobility limitations, but she is able to ambulate within the home with a gait aide. There are no documented impairments that would preclude use of a manual wheelchair for accomplishing her mobility related activities of daily living. She has a history of carpal tunnel syndrome, but has undergone surgical release and has no documented residual impairments causing functionally significant impairment in either upper limb. The records indicate degenerative changes at her spine and shoulder but strength, range of motion and coordination were within functional limits per physical therapy assessment in the patients home. Powered mobility is not medically necessary for the patient to accomplish mobility related activities of daily living and could potentially be less health beneficial than self powered mobility (Hastings, et al; and Valent, et al). In addition, there is no documented face-to-face physician evaluation for mobility related durable medical equipment that has adequately reviewed the patients relevant health and functional history and reported relevant physical examination findings (Johnson and Fitzsimmons). All told, the requested power wheelchair is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for methylphenidate (20 mg extended-release).At issue is whether methylphenidate (20 mg extended-release) is medically necessary to treat the enrollees mental health or substance use disorder as defined in Health and Safety code section 1374.72(a)(3)(A). Adult ADHD, particularly with a history of childhood ADHD, is significantly debilitating and needs to be treated appropriately. Researchers indicate, Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention. A researcher states, Amphetamines and methylphenidate and, less often, nonstimulants (atomoxetine, clonidine, and guanfacine) are used to treat ADHD. Moreover, medical literature shows, Severity of ADHD is improved by methylphenidate pharmacotherapy in routine clinical practice. Based on the medical literature, methylphenidate ER 20 mg is effective and safe for the treatment of adults with ADHD. In this case, the patient was diagnosed with ADHD as a child and did well on methylphenidate. Given that their condition worsened when they were off of the medication, the patient is now seeking to resume their treatment for ADHD. The requested medication is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. For these reasons, methylphenidate (20 mg extended-release) is medically necessary for treatment of the patients medical condition.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 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

A 62-year-old male has requested inpatient mental health services for treatment of depression. Findings:  The physician reviewer found that based on a review of the submitted clinical evidence, the patient did not meet medical necessity criteria for continued stay at an acute inpatient psychiatric unit. It is clearly and consistently documented in the records that during the period in question the patient was not actively suicidal, homicidal, or psychotic. Furthermore, the patient did not have any surgical or medical complications that required 24-hour monitoring or supervision. The treatment the patient received during this period could have been effectively provided at a lower level of care (i.e., partial hospitalization or intensive outpatient).
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested a biliopancreatic diversion with duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that based upon the submitted documentation, the Health Plan has determined that the patient is a candidate for bariatric surgery. In this patients case, the requested procedure is medically indicated, as it is a standard primary treatment for morbid obesity in this clinical scenario. The duodenal switch procedure is an appropriate primary treatment for morbid obesity. It has been approved by the American College of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services based on scientific data including long-term follow-up of over 10 years. The duodenal switch procedure has been shown to result in excellent weight loss outcomes and improvement of comorbid conditions, per the current medical literature. All told, in this patients case, the requested biliopancreatic diversion with duodenal switch is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee has requested substance abuse residential treatment center level of care services for treatment of her substance abuse.   Findings:  The physician reviewer found that the substance abuse residential treatment center level of care services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was initially admitted for Suboxone detoxification from heroin use. She had a relapse after smoking heroin while at home for the weekend. The facility transferred her back to residential level of care, days after said relapse. In this case, the patient does not meet medical necessity criteria for residential treatment detoxification. The patient did not have a documented withdrawal history of delirium tremens, seizures, or acute psychotic reactions secondary to her substance use, she did not have an unstable medical illness that required daily care by a consulting physician, and she did not show active withdrawal symptoms that could not be safely or effectively managed at a lower level of care. Moreover, the patient was fully functioning and without signs of withdrawal present upon admitting psychiatric evaluation. Although the patient does have comorbid bipolar disorder, this did not pose an immediate threat to her safety and did not prevent her from functioning independently and she did not require 24 hour supervision in a residential setting. She was described by staff as motivated to change and participated in the group processes. In addition, the patient has indicated that her family is supportive of her. Based on the American Society of Addiction Medicine criteria, this patient does not meet criteria for residential level of care during the services at issue. Any changes in her medication regimen could have taken place at a lower level of care, as could the monitoring of her bipolar disorder for relapse. Based on the medical literature cited above and the documentation submitted for review, the services at issue were 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 authorization and coverage for psychological testing for evaluation of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for psychological testing is not medically necessary for evaluation of the patients behavioral health conditions. The medical records submitted for review do not demonstrate a clinical indication for psychological testing. In general, ADHD and anxiety disorders are diagnosed with a complete history, physical examination to rule out other causes of problems and a mental status examination. Additional questionnaires, such as the Conners Parent Questionnaire and Teacher Questionnaires are also helpful. In this case, the Parent Questionnaire is consistent with the diagnosis of ADHD. However, there is no Conners Teacher Questionnaire provided for review. In addition, the patients fourth grade report card submitted for review does not show any major concerns. The report card shows that the patient has exceeded standards for listening actively, following directions, staying on task and using time efficiently, completing class work on time, completing homework on time and collaborating well with others. Based on the documentation submitted for review, there is a lack of support demonstrating the medical necessity for psychological testing to evaluation the patients medical condition. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 23-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of his bipolar II disorder. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be more effective than other treatment options.  There is a lack of support for transcranial magnetic stimulation therapy for the treatment of this patients condition.  The safety and effectiveness of the requested services has not been established in this clinical setting.  The patients reported treatment in the current episode of illness includes Lamictal, lithium, Klonopin and Geodon.  At this time, standard therapies remain available to this patient.  More recently, Latuda has been approved for the treatment of bipolar depression and early reports suggest good efficacy and tolerability.  Thus, the requested transcranial magnetic stimulation therapy is not likely to be of greater benefit than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the NMR LipoProfile test for evaluation of the enrollee, who has a family history of hyperlipidemia. Findings:  The 3 physician reviewers found that the records document a family history of hyperlipidemia, but no personal history of hyperlipidemia or clinical cardiovascular disease.  In this circumstance, 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 present in the NMR LipoProfile test, including insulin markers, lipoprotein particle number and size, lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein 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. Therefore, the NMR LipoProfile test provided was not likely to have been more efficacious than other methods of evaluating this patient.  Final Result: The 3 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.