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

The patient is a 50-year-old female with a body mass index of 53. She has requested authorization for laparoscopic adjustable gastric banding (Lap-band). She reports comorbid conditions including asthma, depression, gastroesophageal reflux disease, back pain and obstructive sleep apnea. The patient has completed a psychological evaluation and was found to be an acceptable candidate for bariatric surgery. At issue is whether the requested Lap-band procedure is medically necessary for this patient.Current scientific literature does not demonstrate that Lap-band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not medically warranted in this case. 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: Upheld

A 53-year-old female enrollee has requested for intravenous immunoglobulin (IVIG) for treatment of her lower extremity numbness, burning and pain.  Findings:  The physician reviewer found that the literature supports the use of IVIG for CIDP, but it does not support the use of IVIG for small fiber neuropathy, therefore IVIG is not indicated. Other neuropathy management medications are more appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old male enrollee has requested for acute inpatient hospital services for treatment of the enrollees left-sided weakness, left-sided numbness, difficulty walking and slurred speech. Findings:  The physician reviewer found that the literature is mixed regarding the need for acute inpatient admission for management and evaluation of suspected transient ischemic attack. The literature suggests that clinical risk factors may be used to predict the risk of recurrent stroke. These risks include age greater than 60, diabetes mellitus, symptoms lasting more than 10 minutes, speech impairment and weakness. In this patients case, he reported speech impairment, weakness and symptoms lasting more than 10 minutes. Based on the etiology, workup may include ECG, echocardiogram, carotid ultrasound, MRI/MRA and observation. As per standard management, aspirin was started on the first day of the admission and was then given daily. Based on the patients presentation with the normal physical examination that was consistent with a transient process (whether complicated migraine versus transient ischemic attack), acute inpatient care was not clinically necessary. There is a recognized risk of recurrent transient ischemic attack and stroke in patients presenting with a transient ischemic attack, which speaks to the importance of having rapid follow-up to complete the evaluation. The literature does not distinguish the importance of obtaining a CT versus MRI as the imaging modality of choice. Therefore, the delay between the days for testing was not clinically warranted.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of breast implants and removal of breast capsules. Grossman and colleagues state, What is most important in the evaluation of rupture is just to know if it is a saline or silicone implant. Saline rupture results in the extravasation of a simple saline solution that is harmless and reabsorbed by the body. Researchers note, The most important information in the evaluation of a potential implant rupture is the makeup of the implant present, that is, is it a saline implant or a silicone implant, and how long ago was it placed? Saline implant rupture results in the extravasation of a simple normotonic saline solution that is harmless and will be reabsorbed by the body over time. In this case, the patient has a ruptured saline breast implant from a prior cosmetic breast augmentation. Given that rupture of a saline breast implant presents no risk from the free released saline, and that no risk is presented by the inert breast capsule, the requested services are not medically necessary. Therefore, removal of breast implants and removal of breast capsules is not medically necessary 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 plastic 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 47-year-old female enrollee has requested a PET scan for evaluation of non-Hodgkins lymphoma.  Findings:  The physician reviewer found that Blue Cross guidelines for the use of PET scan clearly state that this diagnostic procedure is indicated in the staging and restaging of lymphoma. There are no further clarifications in the policy. For patients with a relative recent history of cancer, performing serial PET scans is considered the standard of care. PET scan evaluation was medically indicated to rule out recurrence. Additionally, having prior studies available for comparison enhanced the value of the current PET scan.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage of endoluminal gastroplication for the treatment of gastro-esophageal reflux disease (GERD).  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic services for treatment of the enrollees scoliosis and back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of evidence-based guidelines recommending chiropractic treatment in this clinical setting. The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) guidelines do not recognize chiropractic care as an accepted treatment for scoliosis. 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 chiropractor 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 41-year-old female enrollee has requested for an insulin pump and related supplies for treatment of her diabetes.  Findings:  The physician reviewer found that the medical literature supports the use of insulin infusion pumps as a well-accepted method of diabetes therapy for insulin deficient patients. An insulin infusion pump will allow this patient to maintain her glucose levels to near-normal range, with fewer hypoglycemic events, thereby preventing or delaying the onset of diabetes and hypoglycemia related complications.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested for surgical intervention to remove cancerous tumors with limited thoracotomy and pleurectomy decortication for treatment of his mesothelioma. Findings:  The physician reviewer found that the sarcomatoid feature of this patients tumor predicts a lack of meaningful benefit will be achieved by the proposed surgery. Primarily, only pure epithelioid tumors benefit from resection. Although there is some dispute as to the exact staging of this patients disease, which may be somewhat clarified with the proposed laparoscopy and mediastinoscopy, even these exploratory procedures are not indicated as further surgical intervention based upon the information gleaned from these exploratory procedures is not indicated for this patients clinical situation. Again, this is due to the sarcomatoid features of this patients disease which makes any surgical intervention unlikely to provide meaningful improvement in survival and which carries significant risk to the patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that during the course of treatment, the patient continued to struggle with self-defeating behaviors, emotional dysregulation and affective symptomatologies despite comprehensive therapies and psychotropic medication.  On the specified date, the patients mood was noted to be angry. He was upset with his grades.  He was procrastinating.  He was having disharmonious relations with family. The therapist was concerned about the recurrence of significant affective symptoms while the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  In sum, continuation of IOP services beyond the date indicated was consistent with current practice guidelines and relevant peer reviewed literature. Continued IOP services were reasonably expected to improve the patients condition and prevent a more serious health condition. Additionally, the services were safe, appropriate and consistent with good medical practice. Therefore, based on the documentation submitted for review, IOP services during a specified time frame were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old male enrollee has requested testosterone CYP injections 200mg/mL 2MLH, intramuscularly every month for treatment of his decreased libido and fatigue.  Findings:  The physician reviewer found that the patient is not currently osteoporotic.  Recent testing shows osteopenia in the hip and normal, age-appropriate, bone density in the lumbar spine.  The current medical literature does not recommend testosterone therapy for osteoporosis in a patient that is not hypogonadal (low testosterone).  If the patient was osteoporotic one year ago before starting therapy, then he has shown a good response to current treatment. He had one set of laboratory tests that showed a normal total testosterone and low free testosterone, but a subsequent test showed a normal free testosterone.  Thus, at this time, the patient is not hypogonadal.  All told, the requested testosterone CYP injections 200mg/mL 2MLH, intramuscularly every month, are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollees parent has requested authorization and coverage for durable medical equipment (DME) automated external defibrillator (AED). Management of patients with long QT syndrome consists of lifestyle modification, beta-blockers, left cardiac sympathetic denervation and implantable cardioverter defibrillator (ICD) implantation. Prohibition of competitive exercise and avoidance of QT interval prolonging medications are also important aspects of patient management. Indications for ICD implantation include patients who have survived cardiac arrest, have syncope despite adequate doses of beta-blockers, and patients with marked QTc prolongation of more than 550 milliseconds. This patients records do not report that she meets these recognized criteria for an ICD. In the absence of an indication for an ICD in this otherwise low risk patient, there is a lack of support for the requested AED in this clinical setting. Given these findings, the requested DME AED is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility (SNF) services for treatment of his medical condition. Findings:  The physician reviewer found that upon review, the submitted medical records do not establish the medical necessity of skilled nursing facility (SNF) services at issue.  There was no documentation of significant changes in the patients condition, medication or treatment plan. The submitted documentation did not indicate that the patient required the skills of a professional nurse on a daily basis in an SNF setting.  The record reflects that the patient care needs were chronic and custodial.  Skilled therapy was also not required to establish a maintenance program or prevent deterioration in active daily living.  All told, this patient did not require the skilled services of a SNF level of care.  Therefore, 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 internal medicine with sub-specialty certification in geriatric 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

A 20-year-old male enrollee has requested a capsule endoscopy for evaluation of his ulcerative colitis and small intestine enteritis.  Findings:  The physician reviewer found that in the medical literature, Goenka and colleagues noted that although capsule endoscopy has also been used for evaluating established Crohns disease, a high capsule retention rate precludes its use ahead of cross-sectional imaging. Niv and colleagues reported that sequential capsule endoscopy studies are feasible and safe in Crohns disease patients. In patients with complete capsule endoscopy studies, they provide reliable information on mucosal changes in Crohns disease and should be considered as an independent and objective follow-up tool in known Crohns disease patients. However, in this patients case, available records support a diagnosis of ulcerative colitis, not Crohns disease. In ulcerative colitis, small bowel involvement is negligible. Thus, a capsule endoscopy in this patient would be expected to yield little useful clinical information. In the event that the provider requires further reassurance about this patients small bowel status pre-operative to colectomy, a small bowel series and a check of inflammatory bowel markers would be appropriate. Therefore, the requested capsule endoscopy is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested Norco and Soma for treatment of her fibromyalgia.  Findings:  The physician reviewer found that with regard to Norco, the literature indicates that the long-term outcomes of fibromyalgia patients on chronic opiate therapy do not result in functional improvement and may even worsen pain. Fitzcharles and colleagues examined the effect of opioid treatments in patients diagnosed with fibromyalgia over a period of two years. The results of this cohort showed that opioid users had poorer symptoms and functional and occupational status compared to nonusers. Although opioid users may originally have had more severe symptoms at the onset of disease, we have no evidence that these agents improved status beyond standard care and may even have contributed to a less favourable outcome. Another study noted that chronic opioid therapy may increase central sensitization or even lead to events such as opioid induced hyperalgesia (Ngian, et al). All told, the request for Norco is not medically necessary for treatment of this patients medical condition but Soma is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee requested combination therapy consisting of Sovaldi 400 mg tablets, Ribapak (ribavirin) 200 mg tablets, and Pegasys 180 mcg/0.5 ml injection for medical treatment of her hepatitis C genotype 1a.   Findings:  Three physician reviewers found that the prescribed treatment regimen with Sovaldi, Ribapak, and Pegasys is consistent with the most recent and most standardized treatment guidelines for chronic hepatitis virus. Moreover, this regimen is endorsed by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The treatment is greater than 90% effective and consistent with the standard of care. For these reasons, the requested medications are medically necessary for treatment of this patients chronic hepatitis C genotype 1a.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG) 500 mg, quantity 70 units. On review of the current peer-reviewed medical literature and guidelines, there is a lack of support for the requested Gammagard IVIG for treatment of this patients identified glutamic acid decarboxylase antibodies (GAD Ab). Dade and colleagues noted that GAD Ab have been associated with multiple neurological syndromes, including stiff-person syndrome, cerebellar ataxia, and limbic encephalitis. There are limited data supporting the use of IVIG in the treatment of patients with GAD Ab who do not demonstrate symptoms consistent with a GAD antibody syndrome. The available documentation does not establish a known syndrome associated with GAD Ab such as stiff person syndrome, diabetes, autoimmune thyroiditis, pernicious anemia, limbic encephalitis, cerebellar ataxia, or seizure. Therefore, the requested Gammagard IVIG 500 mg, quantity 70 units, is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 neurology with subspecialty certification in vascular 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: Urgent Care
Decision: Upheld

A 59-year-old male enrollee has requested emergency services on an emergent basis for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstance would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patient had low back pain with radiation down his leg for one week prior.  The patient was ambulating without difficulty per the medical records. Vital signs and pulse oximetry were all normal on arrival.  The patient had been seen by his primary care physician and was taking mediations when he presented to the Emergency Department.  He did not have any concerning signs such as weakness or bowel or bladder dysfunction.  The patient had basic low back pain from hip arthritis.  The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a two-year-old male enrollee requested occupational therapy/sensory integration therapy for medical treatment of the enrollees delayed milestones and lack of coordination.   Findings:  Two physician reviewers found that sensory based interventions can be helpful for children who are dysregulated, inattentive, or delayed. However, the current evidence is contradictory on whether occupational therapy for sensory integration therapy provides more benefits as compared to other interventions. The American Academy of Pediatrics Section on Complementary and Alternative Interventions stated that occupational therapy for sensory integration may be helpful, but the research is limited in proving that this has benefit. At this time, sensory integration has an evidence level of D which means there is no evidence of harm from occupational therapy for sensory integration, but the evidence is lacking to prove that this is beneficial or better than other interventions. Consistent with these findings, the requested occupational therapy/sensory integration therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.