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

A forty-seven year-old male who sustained a right wrist fracture is requesting reimbursement for the bone growth stimulator.Reviewers Findings:The reviewing physician found that the use of the bone growth stimulator was indicated under these specific circumstances to aid in the bone healing.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. Based on LOCUS criteria, the patient does not meet criteria for IOP treatment. The patient is at some risk of self-harm (score 2) in the setting of passive suicidal ideation but no active urges, current plan or intent. The patient has shown moderate functional impairment (score 3) as she has not been attending school and has been unable to drive. Since starting IOP, she has been improving in terms of hygiene and in her ability to leave her home. She is planning to return to college in the fall. The patient has no major medical, addictive and psychiatric comorbidities (score 2) with diagnosis of OCD, anxiety and depression. The patients recovery environment is minimally stressful (score 2) as she lives at home with her family. The patients family is supportive (score 2) and they have completed several family meetings. The patients resiliency and treatment history has been limited (score 3) as she has demonstrated some improvement in mood and functioning since admission to the IOP. The patient cares for herself, she is performing activities of daily living, and she is planning to return to college. This gives the patient a composite score of 14, which is consistent with low intensity community based services. The patient has participated in several weeks of the IOP and demonstrated improvement in mood, activities of daily living, and overall functioning. Based on her clinical improvement and lack of safety concerns, transition of this patient to outpatient level of care should help maximize her independence and functioning. For these reasons, the IOP services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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 57-year-old female enrollee has requested Euflexxa injections for treatment of her osteoarthritis.  Findings:  Three physician reviewers found that in this patients case, Euflexxa injections are not likely to be the most beneficial treatment alternative. This patient has progressive degenerative osteoarthritis of the ankle following allograft procedure combined with a varus deformity at the foot/ankle. The submitted documentation indicates that she has had a good response with steroid injections. A review of the literature indicates that Euflexxa, or hyaluronan injections, within the ankle joint remains controversial. In a review of nonsurgical management of osteoarthritis, Grogan and colleagues concluded that additional studies are required prior to assessing the efficacy of hyaluronic acid use in the foot and ankle. Cohen and colleagues followed thirty patients in a randomized prospective study. These patients were followed with a subjective ankle osteoarthritis scale. Their conclusion was that sodium hyaluronate may be a safe and effective option for pain, although larger studies are needed.  Therefore, at this time, there is insufficient evidence demonstrating that Euflexxa injections are likely to be the most beneficial treatment for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging for evaluation of the enrollees chronic elbow pain. Findings:  The physician reviewer found that for this patient, a repeat MRI was indicated. The MRI done earlier was interpreted with less than definitive findings.  In addition, the pediatric orthopedist felt that the MRI appeared normal. Imaging of the elbow in a pediatric patient is often confusing, as there are multiple ossification centers that can have a range of normal appearances.  The most optimal imaging will generally be done at a center accustomed to imaging young patients, and at a center more specialized in orthopedics. Considering that the results of the MRI will possibly determine whether this patient undergoes surgery, it is reasonable to repeat the study at a dedicated pediatric orthopedic hospital. For these reasons, MRI was medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for increased dose of morphine or prescription for Percodan for treatment of the enrollees back, hip and neck pain. Findings:  The physician reviewer found that In the peer-reviewed medical literature, colleagues noted that opioid risk mitigation tools should be part of practice and when patient safety issues are identified such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should be discontinued. Colleagues reported that opioids are not recommended as first-line therapy but when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. In addition, urine drug testing may be used as a tool to monitor for aberrant behavior or drug misuse. In addition, current guidelines support use of opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Pain assessment should include current pain, the least reported pain since the previous assessment, average pain, and intensity of pain after taking the opioid, how long it takes for pain relief, and how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. This patients medical records report chronic pain as well as noncompliance with medication regimen, which suggests the patient is at risk in regard continued use of opioids. All told, the medical records do not support chronic use of either morphine or Percodan in this clinical setting. Thus, the requested increased dose of morphine or prescription for Percodan are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested a breast lift and reduction for the treatment of her symptomatic macromastia. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the procedures at issue were reconstructive in nature. Breast reduction removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion with a patients body and to alleviate discomfort associated with overly large breasts. While the presurgical photographs show a female with large pendulous breasts, the patients condition is not considered an abnormal structure of the body. There is no evidence of breast asymmetry or of disease or infection affecting the breast tissue. The removal of only 250 grams from each breast demonstrates that the patients breasts were not excessively large so as to constitute an abnormal structure. As such, this patients condition did not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. Thus, the procedures at issue do not meet the definition of reconstructive surgery as defined in California law. Concerning general concepts of medical necessity, the reduction of 250 grams of tissue from each breast falls below the Schnur Sliding Scale Chart guidelines. According to Schnur, the volume of reduction can be used to distinguish cosmetic from functional breast reduction surgery. The reduction of 250 grams per breast falls below the 22nd percentile. Reductions above the 22nd percentile are considered medically necessary. Although the patient reported she was asymptomatic following surgery, it is unlikely that a reduction of only 250 grams of tissue from each breast will provide long-term relief from her musculoskeletal pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a Flexitouch Pneumatic Compression Device and garment for treatment of his medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the requested services have been established as medically necessary. The patient received physiotherapy sessions with elevation, exercise, compression, wrapping, and compression stockings. He used a non-programmable pump for an extended period of time which did not fit well and was painful. According to the patients clinician, the non-programmable device was ineffective in treating the lymphedema. Moreover, the Flexitouch system has shown better outcomes in randomized clinical trials and other studies (Fife, et al; Muluk, et al; Ridner, et al). Progressive disease on the standard device has been sufficiently documented and the use of the Flexitouch device is medically appropriate and necessary. Given the above, the requested services are medically necessary for treatment of the 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 medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rytary. The U.S. Food and Drug Administration (FDA) approves the use of Rytary (generic name carbidopa and levodopa) for the treatment of Parkinsons disease. Hauser notes that levodopa remains the most effective medication to treat Parkinson's disease, and that extended-release carbidopa-levodopa is designed to achieve rapid absorption and onset of clinical benefit and to provide sustained therapeutic levodopa levels and duration of clinical benefit. The author further noted that extended-release carbidopa-levodopa was demonstrated to be efficacious in early Parkinsons disease compared with placebo, and in moderate-to-advanced Parkinsons disease, it provided more sustained clinical benefit with fewer dose administrations than carbidopa-levodopa immediate release. In this case, the patient has a diagnosis of Parkinsons disease and has tried and failed alternative therapies. Given that current medical literature supports Rytary as an effective and well-tolerated medication for Parkinsons disease, the requested medication is medically indicated. Therefore, Rytary is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested magnetic resonance imaging (MRI) and surgical repair of a sports hernia for treatment of his hernia. Findings:  The physician reviewer found that athletic pubalgia, or sports hernia, is a complex entity and often difficult to diagnose as it does not have the same clinical exam findings found for classic inguinal hernias. The location of symptoms is generally in the lower abdomen, groin, pubis, thigh adductors and hip flexors. Hyperextension of abdomen or hyperabduction of the thigh can lead to resultant damage of muscular insertions causing pain. These injuries tend to occur more commonly in athletes. The patients constellation of symptoms and lack of improvement with conservative measures are suggestive of a groin hernia. The peer reviewed medical literature suggests that when patients with similar symptoms fail to improve with rest and rehabilitation, the condition is unlikely to improve without surgical intervention. This patients bone scan showed inflammation at the pubis and temporary relief was experienced with local anesthetic injection into the adductor tendon. These clinical findings tend toward a diagnosis of sports hernia. This patient continues to experience symptoms despite rest, activity modification, and pain medications. As such, the surgical intervention proposed is medically appropriate and necessary. A pre-operative magnetic resonance imaging (MRI) scan has also been requested. MRI has evolved into a standard pre-operative test to document the extent of the groin injury. MRI is known for its high sensitivity and sports hernia specialists routinely use MRI to diagnosis the etiology of sports hernia and to assist in operative planning. Therefore, the use of the MRI in pre-operative planning for repair of this patients condition is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patients abuse of opiates, benzodiazepines and cannabinoids use was impairing his daily routine and contributed to significant impairment across multiple domains of functionality. The patient was unable to sustain employment and lost his apartment.  His motor vehicle license had been revoked due to substance use.  He was prescribed psychotropic medications including an atypical antipsychotic. This patient had reportedly tried buprenorphine prior to the episode of care, although the documentation did not specify if it was obtained illicitly or by prescription. Upon presentation, the patient was malnourished, circumstantial, anxious, agitated and depressed.  He endorsed symptoms consistent with a withdrawal syndrome.  Finally, despite outpatient services and a brief residential stay during the episode of illness, the patient was unable to maintain sobriety in his environment.  The patient was clinically unstable and had not consolidated the treatment gains necessary to succeed in the outpatient setting and promptly would have relapsed in a community based setting if he was not admitted that day. However, the patient had positive support from this patients family and a recent three and half year history of sobriety. The patient also has prior success with community programming. The documentation supports that 2 weeks of services were medically necessary.  The two weeks of treatment would have been reasonably expected to improve this patients condition and prevent a more serious episode of illness while fulfilling the initial projected length of stay and providing a total of four weeks of residential treatment, which would be a duration of care consistent with community standards. For these reasons, a portion of the residential treatment center services was medically necessary for treatment of this patients medical condition. Specifically, the residential treatment center services for 2 weeks were medically necessary, but not thereafter. Final Result: The reviewer determined that the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld

A fifty-four year-old female who is status post a buniectomy with left foot pain is requesting authorization of interferential stimulation therapy.Reviewers Findings:The three reviewing physicians found that there is insufficient evidence to show that the proposed therapy would help alleviate post-operative pain and swelling.  The physicians concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested physical therapy for treatment of her degenerative disc disease.  Findings:  The physician reviewer found that while exercise therapy is beneficial for neck and shoulder pain, this patients condition is chronic and recurrent. Further, the patient was already independent on a HEP during her previous physical therapy sessions. Although manipulation is known to provide short-term relief, the physical therapy at issue was not medically necessary given the chronicity and recurrent nature of the patients neck and shoulder pain and her ability to manage her condition through the HEP.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical and lumbar epidural steroid injections for treatment of his medical condition. Findings:  The physician reviewer found that the request for cervical and lumbar epidural steroid injections are not medically necessary. In this case, the patient presents with chronic low back and neck pain. Based on the clinical documentation submitted for review, the patients pain is primarily located in the neck and low back without signs of radiculopathy. There is support in the medical literature for the use of epidural steroid injections in radiculitis from disc herniation and spinal stenosis. However, without documented radiculopathy or radiculitis, the use of epidural steroid injections is not clinically indicated. In addition, physical therapy was noted to be tried, however the patients response to the therapy is unknown. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.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 anesthesiology and pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 21-year-old female enrollee requested ambulance transport on an emergent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought ambulance transport. Based upon the medical records provided, the patient presented with flu-like symptoms with normal vital signs and without respiratory distress, shortness of breath or chest pain.  Thus, her symptoms were not of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place her health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did not meet prudent layperson criteria for ambulance transport.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollee, who has a family history of breast cancer. Findings:  The physician reviewers found this patients mother fulfilled criteria for genetic testing to test for heritable risk for breast cancer. Now, since she is deceased, the patient has incomplete data on which to make decisions regarding her breast cancer risk. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic and gastric cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this patients case, the MyRisk panel was appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, gene testing was likely to have been of greater benefit than other available modalities for evaluating this patient. Final Result: Two of three reviewers determined that the 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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.