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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. Findings: The physician reviewer found that the medical literature has demonstrated a reduced rate of referral for diagnostic coronary imaging following PET as compared to nuclear stress testing with single photon emission computed tomography (SPECT). Some studies have shown a decrease in the use of downstream angiography and revascularization when utilizing PET compared to a SPECT matched group. In the case of this patient, evaluation for ischemia was appropriate given the patients symptoms and prior history of multiple coronary interventions. In addition, the low ejection fraction and wall motion abnormalities on echocardiography required a functional study to plan a possible reperfusion strategy. Conventional coronary angiography would not have provided this type of an assessment. In addition, her previous allergic reaction to technetium precluded the use of nuclear imaging with SPECT. Therefore, the PET scan performed was likely to have been more beneficial for evaluation of this patients medical condition than the available standard techniques. Final Result: Two of the three reviewers determined services at issue were 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patient has short stature and appropriate slowing of his growth velocity at the end of puberty. He has normal growth factors, a normal GH response on provocative GH testing, and no known morphological abnormalities of his pituitary gland. His bone age previously showed nearly fused epiphyses, and at this point in time, he is not expected to experience acceleration in growth velocity with GH therapy. This patient does not have GH deficiency, and his bone age is too mature to consider a trial of GH therapy for idiopathic short stature. Thus, GH is not clinically indicated. Based on the medical literature cited above and the documentation submitted for review, the request for Genotropin is not medically necessary for treatment of the patients medical condition. 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 pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a ten-year-old female enrollee has requested occupational therapy for the treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  Two physician reviewers found that this patient has been extensively evaluated and followed by a developmental pediatrician for a prolonged period prior to the recommendation for occupational therapy. The patients pediatrician has recognized that, in addition to medications, the patient requires occupational therapy. Schaaf and colleagues noted the effect of occupational therapy using a sensory integrative approach in children with developmental disorders. Miller and colleagues conducted a study that was a controlled investigation into the effectiveness of this technique. The requested occupational therapy is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for pulsed radiofrequency neurolysis to the cervical and thoracic spine for treatment of her cervical and thoracic spine pain.   Findings:  Two physician reviewers found that the relevant scientific evidence includes a study by Tekin and colleagues which concluded that pulsed radiofrequency neurolysis is not as long lasting in its results as conventional radiofrequency. The authors noted that although a decrease in pain scores was maintained in the conventional radiofrequency group at six months and one year, this decrease in pain was discontinued in the pulsed radiofrequency group at the follow-up periods of six months and one year. They also noted that the number of patients not using analgesics and patient satisfaction were highest in the conventional radiofrequency group. Similarly, Falco and colleagues noted that there are few peer-reviewed studies on pulsed radiofrequency, and therefore their review was based on conventional radiofrequency.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for sclerotherapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients varicose veins. The submitted documentation does not support the medical necessity of the requested services. The patient has a history of deep vein thrombosis that does not seem relevant to the patients 1 to 2 mm varicosities. In addition, there is no clarity regarding the patients reflux. The presence or absence of reflux in this case is not relevant as to whether the sclerotherapy should be covered in any case. Treatment of branches is covered for veins typically greater than 3 mm. Based upon the documentation provided, the patient does not meet this criteria. Therefore, the requested sclerotherapy is not medically necessary for the treatment of the 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 vascular 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 female enrollee has requested reimbursement for genetic testing (Colaris PMS2) for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that the patient was diagnosed with cervical polyps. She is adopted and recently found out about a family history of cancer. Her mother reportedly had ovarian cancer in her 50s and her sister had duodenal cancer in her 40s. The patient also reported that her uncle had colon cancer. The patient subsequently underwent comprehensive BRCA analysis and Colaris testing. She is requesting reimbursement for the gene-specific Colaris PMS2 analysis. Lynch syndrome is a genetic susceptibility to the development of a variety of different cancer types that occur in certain families.  Lynch syndrome is detected by Colaris and concurrent PMS2 sequencing. The current medical guidelines support the requested testing for individuals without a personal cancer history if they have two or more first-degree or second-degree relatives with a Lynch related cancer, such as colon cancer.  According to the patient, she has three relatives, who have had cancers that fall within the types seen in Lynch syndrome (ovarian, colon and small intestinal). Therefore, she does fall within the guidelines for the testing at issue. In this clinical setting, the genetic testing was likely to be of greater benefit than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female in good health with the exception of hemodynamic stable mitral valve prolapse. She requires extraction of impacted molars. Her cardiologist indicates she is a low risk for significant coronary artery disease and mitral valve regurgitation, which requires antibiotic prophylaxis prior to oral surgery. There is no information from the oral surgeons office indicating anything unusual concerning extraction of the patients teeth. The patient is seeking authorization for inpatient hospital and general anesthesia services in association with her oral surgery. The Health Plan has denied this request.Based upon the information provided there is no cardiovascular of other medical condition which would require the use of hospital based general anesthesia for the proposed oral surgery. This type of oral surgery for a person with stable mitral valve prolapse would best be performed in the office setting. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a six-year-old male enrollee requested tocilizumab (Actemra) for six months for medical treatment of the enrollees medical condition status post kidney transplant. Findings:  Three physician reviewers found that the treatment of acute antibody-mediated rejection by any modality is not currently supported in the peer-reviewed medical literature (Kasiske, et al). Based on available data, this patient should receive immunoadsorption or plasmapheresis plus bortezomib with close monitoring by his physician (Roberts, et al). Currently, the use of Actemra should be limited to clinical trials. All told, the requested Actemra for six months is not likely to provide this patient with a greater benefit than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. On an initial evaluation, the patient reported chronic suicidal ideation and numerous suicide attempts. He reported other behavioral issues as well as problems with impulse control and numerous eating disorder symptoms. The patient reported relational issues with his family. During the disputed period, he reported suicidal thoughts. It does not appear that he was acting on these thoughts during that time. He often expressed resistance to treatment and was making minimal progress in his compliance with eating prescribed amounts. He expressed symptoms of depression as well as anxiety that continued regarding his weight gain. Based on the records, residential treatment was effective for the patient in terms of reducing suicidal ideation as well as reducing eating disorder symptoms. The medical evidence supports the services at issue in this clinical setting. All told, residential treatment center services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

The patient is a 50-year-old female with a history of significant pain secondary to osteoarthritis of the hip. Anti-inflammatory medications and injections did not provide sufficient relief of the patients symptoms. The patient consulted two orthopedists; one recommended total hip replacement and the other suggested hip resurfacing arthroplasty. The patient decided to undergo the latter, which was performed in February 2005. At issue is whether hip resurfacing arthroplasty was medically necessary for treatment of the patients medical condition.  Hip resurfacing arthroplasty is an experimental procedure without proven efficacy. The current standard of care for the patients condition is a total hip replacement. Complication rates associated with hip resurfacing arthroplasty have been high in the short to mid-term. Furthermore, there is no data on the long-term efficacy and risks of the procedure. Given the current results of hip resurfacing arthroplasty, the procedure cannot be recommended at this time. Based upon the information set forth above, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old male enrollee has requested reimbursement for substance abuse sub-acute detoxification for treatment of his alcohol dependence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Based on the history of alcohol consumption, this patient was at high-risk for an alcohol withdrawal syndrome.  Since the detoxification services were expected to improve the patients condition and prevent a more serious medical condition, placement in a 24-hour setting was medically necessary and consistent with good medical practice.  However, this treatment setting was no longer medically necessary as of the date indicated.  The patient had no history of complicated alcohol withdrawal, seizures, or delirium tremens.  His last drink was two days prior to admission.  The patient was treated with a 5-day benzodiazepine taper.  The records indicate that he was normotensive throughout the treatment course, and he had no tachycardia.  Thus, following the 5-day treatment course, the sub-acute detoxification services were no longer medically necessary.   Despite the diagnosis of depression, the patients mood, thought content and thought processing were described as appropriate.  He was stable on an antidepressant, and he was motivated for recovery and had a supportive family.  This patient had prior success with 12-step programming, but had not augmented this family and social support with specialty treatment services in a less restrictive setting, such as intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  Thus, the residential rehabilitation services at issue were not medically necessary for treatment of the enrollees medical conditions.  All told, substance abuse sub-acute detoxification services provided from the specified timeframe were medically necessary.  However, substance abuse sub-acute detoxification services were not medically necessary from the specified timeframe.  Additionally, substance abuse residential treatment services provided from the subsequent specified timeframe were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for circumcision for treatment of his irritation of the foreskin. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient has irritation of the foreskin.  However, there is no documentation of recurrent urinary tract infections, phimosis, penile cancer, recurrent posthitis or balanitis or traumatic injury to the foreskin. The current medical literature does not support circumcision in this clinical setting. Final Result: The reviewers 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. A mental health crisis is an acute disturbance of behavior, thought or mood of a patient which if untreated may lead to harm, either to the patient themself or to others in the environment. Thus, the definition of a psychiatric emergency differs from other medical emergencies in that the danger of harm to the society is weighed in determining the appropriate level of care. Mental health emergencies or crises also can include acute conditions that could quickly deteriorate into dangerousness or inability to care for self, even if those issues do not currently pose a problem. The services rendered during the time period under review do not meet the definition of urgent care services and care as defined by California law. The patient did not require services to prevent the serious deterioration of his health resulting from an unforeseen illness. The patient was under the care of a local provider, who advised the patient to establish care by his school, but this was not reportedly accomplished. In addition, the patients presenting symptoms do not meet the definition of a psychiatric emergency or mental health crisis. Although the patient was experiencing mental health distress as evidenced by his report of increasing depressive symptoms over a four month period, the records do not support that the patient was experiencing a mental health emergency or crisis with acute suicidal ideation with plan or intent that necessitated urgent mental health services before the patient was able to return to the Health Plans service area. For these reasons, the services provided were not urgent care services as defined by California law.Final Result: The reviewer determined that the services at issue were not urgent care services 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 subspecialty 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 patients parent has requested reimbursement for orthodontic services, CPT D8670. Generally, a handicapping labio-lingual deviation (HLD) score over 25 describes a handicapping malocclusion requiring orthodontic treatment. In this case, while the documented HLD score was 27, the submitted records appeared to show that this score was high. In this clinical setting, generous calculation of the HLD score would be 22, below the threshold for a handicapping malocclusion. Therefore, orthodontic services, CPT D8670, were not medically necessary for the treatment of this patient.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 licensed D.D.S., board certified in dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old man with a diagnosis of end-stage arthritis of the ankle joint. He has requested authorization and coverage for fresh osteochondral allografting to alleviate his pain. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.Fresh osteochondral allografting is not within the standard of care for treatment of the patients condition. End-stage arthritis of the ankle joint is treated with medications, injections, bracing, and eventual arthrodesis if the pain persists. For some patients, arthroplasty is an option. While allograft procedures have been helpful for smaller lesions, severe arthritis requires significant coverage. There are no long-term, prospective studies available outlining the risks, benefits, complications or outcomes of fresh osteochondral allografting in this clinical setting. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.