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

Nature of Statutory Criteria/Case Summary: When there is concern about a patients inability to return home from the acute setting, SNF care can be considered. SNF services are supervised by a physician and nursing is provided 24-hours per day. In addition, physical therapy and occupational therapy are available. As noted in the medical literature, SNF care is supported as medically necessary when the patient requires skilled nursing or rehabilitation services at least five days a week. These services require the expertise of trained professional health care providers. This patient is status post severe motorcycle trauma with multiple fractures of the lower extremities. He continues to be non-weight bearing, and requires two to three people to assist his transfer to a wheelchair. He is noted to be unable to move his right foot and needs high dose opioids for pain. Frequent repositioning in bed is also indicated in order to avoid ulcer formation. Moreover, the patient has significant functional impairments which limit ambulation and his ability to perform activities of daily living. The providers reported that his wife is unable to physically care for the patient alone, monitor the high doses of opioids, and position his extensively traumatized body in order to avoid ulcers. Given these findings, the requested SNF services 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 internal medicine with expertise in skilled nursing facilities 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 the Levia ultraviolet B scalp comb for treatment of her medical condition. Findings:  Three physician reviewers found that the requested services are likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Psoriasis is a chronic inflammatory skin disease typically presenting with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Treatment of psoriasis usually starts with topical agents, such as corticosteroids as well as phototherapy. More recently, narrow-band UVB (NBUVB) has emerged as an effective treatment modality. The spectral output of Levia is in the wavelength. With Levia UVB scalp comb, NBUVB is delivered directly to diseased tissue, without exposing neighboring, healthy skin. This targeted approach allows for the delivery of higher doses of UVB light than would be practical by the use of traditional light-box equipment. As a result, the cumulative dose of UVB light required for disease remission can be delivered in fewer treatment sessions. In this case, the patient presents with moderate to severe scalp psoriasis. In-home therapy is indicated as her treatment is expected to be long-term, and she requires frequent treatments. For the reasons stated above, the Levia UVB scalp comb is 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  All three reviewers are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested a consultation with an orthopedic specialist for evaluation of her bone spurs and pain in the left shoulder. Findings:  The physician reviewer found that upon reviewing the relevant medical literature, Blair and colleagues reported on the positive outcomes associated with corticosteroid injections in the management of shoulder pain resulting from impingement. In addition, Arroll and Goodyear-Smith concluded that corticosteroid injections are probably more effective than non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute or subacute tendonitis. Morrison and colleagues found that patients between 40-60 years of age have the best results from injections. Some research, as reported by Green and colleagues discuss the usefulness of physical therapy as an adjunct, but conclude that it still requires further study. In the present case, the patient has documented impingement syndrome and has had a prior good response to corticosteroid injection. Continued orthopedic management, with additional injections as needed, is appropriate unless her condition progresses such that she requires surgical intervention. At this juncture, pain management is not appropriate since the patients disease process is amenable to specific therapy in lieu of only attempting to control her pain. Therefore, this patients need for further care with an orthopedic specialist has been demonstrated and is therefore medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 17-year-old female enrollee has requested Zithromax intravenous injection therapy for the treatment of the enrollees Lyme disease. Findings:  Three physician reviewers found that the evidence that the patient has chronic neuroborreliosis or post-Lyme encephalopathy is based on non-specific testing and symptoms that are non-specific.  Evidence for the use of long-term intravenous antibiotics for chronic neuroborreliosis or post-Lyme disease is inconclusive. The treatments are not without risk and there are insufficient data in the peer-reviewed medical literature to support a conclusion that they are effective. At this time, it has not been established that the benefits of the proposed therapy outweigh the risks, and the treatment remains of unproven efficacy for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar spinal fusion for treatment of his post laminectomy syndrome.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Anatomical studies have documented prior laminectomy, but these studies raise the question as to whether or not there has been an adequate decompression of spinal nerve root impingement.  The records document congenital central spinal stenosis and multiple levels of neural foraminal stenosis.  The medical records do not document lateral flexion extension views with demonstration of instability.  While the documents reviewed are consistent with an L5 spinal nerve root dysfunction, extruded intervertebral disc is stated to be present proximal to the level that typically would affect the L5 nerve root.  There are conflicting statements concerning the efficacy of conservative management to date.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested lumbar spinal fusion is not medically indicated for the treatment of this patient.  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 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

A 51-year-old female has requested coverage for a power wheelchair for treatment of her degenerative joint disease, diabetes mellitus, shortness of breath, and bilateral carpal tunnel syndrome.  Findings:  The physician reviewer found that the documentation provided for review supports the medical necessity of a POV for this patient. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, the determination of medical necessity for a POV is based on the following criteria: 1) the patient is unable to ambulate independently with use of an assistive device; 2) the patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) the patient has demonstrated the ability and willingness to safely operate a POV; 4) a POV is needed to perform in-home MRADLs; and 5) the patients residence will accommodate such a device. In the case under review, the records indicate that the patient is non-ambulatory despite use of an assistive device and unable to self-propel a manual wheelchair due to bilateral CTS. She was previously using a power wheelchair and her home is noted to be able to accommodate the device. Therefore, the records support the medical necessity of the prescribed power wheelchair for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy, physical therapy and occupational therapy  for treatment of the enrollee, who has been diagnosed with developmental delay and seizure disorder. Findings:  The physician reviewer found that Speech and language therapy is particularly important for children with developmental delay to facilitate development of functional communication skills to express needs. Children with global developmental delay are also at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information.  It is important to thoroughly address these deficits to prevent further impact on growth and development.  This patient has made progress with speech and language therapy.   Additionally, occupational therapy is medically necessary in this patients case.  This patient has delays in fine motor skills, self-help skills, and feeding skills.  Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. In addition, with its focus on developing self-help skills, including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patients case.   Physical therapy is medically necessary to address this patients delays in gross motor skills.  This patient demonstrates gross motor delays in both stationary and locomotion skills, with challenges in standing, ambulation, and equilibrium reactions.  He has made gains in gross motor skills, but continues to require significant assistance.  The requested physical therapy will allow this patient to improve and safely navigate through his environment.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a five-year-old male enrollee has requested hippotherapy for treatment of the enrollees cerebral palsy.  Findings:  Three physician reviewers found that hippotherapy is considered investigational, as there have been no significant studies documenting its effectiveness. While there have been some anecdotal reports of benefit, these reports are not sufficient to establish that hippotherapy results in a superior clinical outcome to standard physical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested Synvisc injections for treatment of his osteoarthritis of the right shoulder glenohumeral joint.  Findings:  Three physician reviewers found that Synvisc is safe and effective for the treatment of pain due to osteoarthritis of the knee in patients who have failed to respond adequately to conservative, non-pharmacologic therapy and to simple analgesics.  It is a well-established modality for use in the knee. Synvisc has not been established as a safe and effective treatment for pain due to osteoarthritis in joints other than the knee. Its use in the treatment of shoulder arthritis is of unproven benefit at this time. There is a lack of peer-reviewed, published data supporting the safety and efficacy for the use of Synvisc injections for this patients condition. Prospective, randomized, controlled trials need to be undertaken to establish whether viscosupplementation has a clinical role in the treatment of patients with osteoarthritis of the shoulder. All told, Synvisc injections are not likely to be more beneficial than other available standard therapies for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested nerve testing (autonomic testing) for evaluation of her orthostatic dizziness, fibromyalgia, Ehlers-Danlos syndrome (EDS) and fatigue.  Two physician reviewers fund that this patient presents with a complex medical history with symptoms suggestive of Postural Orthostatic Tachycardia Syndrome (POTS). Autonomic testing is a widely used group of tests typically performed in specialized autonomic laboratories. This testing is useful in a variety of clinical situations, and has been utilized in patients with fibromyalgia and symptoms of lightheadedness and dizziness to tease out autonomic neuropathy from POTS, cardiac problems, and other conditions that can be difficult to diagnose. In this case, the utilization of autonomic testing was likely to be more beneficial than standard testing. Final Result: Two reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assayFindings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. DecisionDx-Melanoma gene assay is an analysis of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. Researchers reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients who had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data relates to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma gene assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene assay was not likely to have been superior over 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her medical condition.   Findings: The physician reviewer found that this patient has severe osteoporosis and is young for this condition. Her provider has noted concern with her very low bone mineral density and T-score at her age and has recommended an anabolic agent. Since the patients bone mineral density is in the severe osteoporotic range, and she has sustained fractures, the requested Forteo 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 internal medicine with sub-specialty certification in endocrinology 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: Overturned

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for private duty nursing services, including 40 hours per week of services with a licensed vocational nurse, 16 hours per week of services with a registered nurse, and one to two visits per certification period of registered nurse supervisory services.Dravet syndrome is a severe encephalopathy characterized by prolonged febrile and afebrile seizures starting some time in or after the first year of life. Prior to onset of seizures, infants are developmentally appropriate. The seizures frequently become treatment-resistant, and patients over time develop cognitive, motor, and behavioral delays. Most cases are caused by a mutation in the sodium channel gene SCN1A, although other genes have also been implicated in cases with similar presentations. Patients may manifest multiple types of seizures, including myoclonic seizures, absence seizures, and complex partial seizures. One of the key features of Dravet syndrome is fever sensitivity. Some patients may have seizures triggered by a hot bath, hot weather, or exercise. Photosensitivity may also occur. Treatment includes anticonvulsant medications and seizure prevention, when possible. Infection prevention and treatment of fevers is important, and prevention of overheating from weather and activity is also necessary. This patient has a number of skilled nursing needs. He is at risk for seizure activity, aspiration, hypoxia, skin breakdown, neurostorming with severe spasticity causing pain, and abdominal pain with vomiting from feeding intolerance. This patient requires constant monitoring and frequent interventions around-the-clock. The requested private duty nursing hours with registered nurse supervision are medically necessary and appropriate. Therefore, private duty nursing services, including 40 hours per week of services with a licensed vocational nurse, 16 hours per week of services with a registered nurse, and one to two visits per certification period of registered nurse supervisory services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bronchoscopic thermoplasty (CPT 31660). Findings:  The physician reviewer found that Bronchoscopic thermoplasty has been approved by the U.S. Food and Drug Administration (FDA) and there are data to support its use in patients with severe persistent asthma whose symptoms persist despite maximal treatment. Further, bronchial thermoplasty has been endorsed for use in specific patients with severe persistent asthma by organizations including the American College of Chest Physicians and the American College of Allergy, Asthma and Immunology. Moreover, bronchoscopic thermoplasty has also been shown to be safe in follow-up studies. This patient presents with daily symptoms despite adequate medical therapy. She has no reported contraindication to bronchoscopic thermoplasty. Thus, the requested bronchoscopic thermoplasty (CPT 31660) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. One reviewer found that the requested bronchoscopic thermoplasty (CPT 31660) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care 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: Upheld

The spouse of a 54-year-old male enrollee has requested for continued acute inpatient rehabilitation for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient does not meet all the Medicare criteria for continued acute inpatient rehabilitation as: he does not require 24-hour close medical supervision by physician, he does not require 24-hour rehab nursing and he does not require intensive rehabilitation as his participation was limited due to agitation and decreased ability to follow commands.