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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cervical epidural steroid injection for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records do not document that the patient has had adequate trials of conservative therapy.  The clinical notes do not provide details regarding recent physical therapy, trial of nonsteroidal anti-inflammatory drugs, or chiropractic therapy.  Additionally, the patient has poorly controlled diabetes, which an epidural steroid injection may worsen.  The progress note does not describe the patient as having radiculopathy. The current medical evidence supports conservative therapy as a first step in this clinical setting.  All told, the requested cervical epidural steroid injection 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 anesthesiology 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The parent of an enrollee has requested coverage for inpatient psychiatric treatment services. The health plan has denied this request as not medically necessary. The records indicate the enrollee with a history of anorexia nervosa, anxiety disorder, and depressive disorder was admitted for inpatient psychiatric treatment for treatment of eating disorder symptoms. She had acute food and fluid refusal, was over exercising, had reports of passing out, having blackouts, having compromised vitals, and requiring nasogastric tube placement for feeding in the past.  She had behavioral dysregulation, elopement attempts, was agitated and inconsolable. She had suicidal ideation and did not want to live with depressive and anxiety symptoms.  She had diagnoses of anorexia nervosa, generalized anxiety disorder, and depressive disorder.  She had past hospitalizations and had past partial hospital program, residential, and outpatient treatment.  She took Duloxetine and Zyprexa, and had taken Abilify, Celexa, and Ativan.  She was discharged and the plan was to transfer her to residential treatment and keep her in the hospital until the transfer. According to the medical literature, patients with serious medical consequences due to eating disorder symptoms, severe weight loss or poor nutritional status are candidates for inpatient treatment.  A review of the medical records documents a patient with a severe and acute eating disorder with significantly abnormal vital signs requiring medical interventions due to the life threatening nature of her behaviors related to her eating disorder. In this case, this patient had reports of acute food refusal and had past complete starvation to the point of passing out, having blackouts and requiring nasogastric tube placement for feeding.  She had other behavioral and mood symptoms before and during her hospital stay.  She needed to remain in this 24 hour setting as she could not safely be treated outside of this setting. Final Result: The reviewer determined that the requested service is medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should beoverturned. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested for CT angiography for evaluation of his coronary artery disease. Findings:  Three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset and is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress test. CT angiography is also not a medically acceptable substitute for coronary angiography, as CT angiography would not be able to accurately confirm or exclude important coronary obstruction. The use of CT angiography for evaluation of graft patency is an uncertain indication with todays technology.
Appeal type: Medical Necessity
Decision: Overturned

The patient has been diagnosed with acquired hallux valgus, capsulitis, bilateral foot pain, and difficulty walking. The patient was noted to have bilateral bunions. The patient reported big toe pain, foot pain, and pain with range of motion of the great toe joint in bilateral feet. The physical examination revealed muscle strength rated as five out of five. No weakness or muscle imbalance was noted. A slight increase in the angle of the first metatarsal phalangeal joint with medial deviation of the bilateral hallux was noted. The provider noted an x-ray of bilateral feet revealed a bunion formation greater on the right side with midtarsal pronation. The patients parent has requested authorization and coverage for custom foot orthotics. Researchers reported that a hallux valgus (HV) deformity (bunion) is a common, potentially debilitating deformity consisting of lateral deviation of the hallux on the first metatarsal. Researchers also reported possible treatments include orthoses to improve support and alignment. Medical literature reported that conservative options for addressing the medial column include custom foot orthotics and bracing. In this case, the patient reported painful hallux valgus/bunion deformities bilaterally with x-ray confirmation of hallux valgus and midtarsal pronation. The medical evidence supports the requested equipment in this clinical setting. Therefore, custom foot orthotics are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 podiatry 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: Overturned

A 39-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she 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.Second degree burns are more serious than first degree burns due to the loss of tissue.  Hand injuries are also at higher risk for infection and complications than other parts of the body. In general, patients with burns should receive immediate medical attention. This patient reasonably believed she had a medical condition including significant pain and potential body part impairment and/or serious dysfunction of her hand which justified follow up in the ED on the date of service in question as instructed by the emergency physician who examined her the day before. In light of the discharge instructions the patient received during her initial ED visit indicating that she should return to the ED the following day, the patient met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested cervical artificial disc surgery (CPT codes 22551, 22856, 22845, 22851, 20930, 63048, 63020, 63045 and 69990) for treatment of his cervical spinal stenosis and cervical radiculopathy.  Findings:  Three physician reviewers found that the request for cervical artificial disc surgery is not likely to be more effective for this patient than other available options. The study by Botelho and colleagues reviewed the data concerning the role of cervical arthroplasty in reducing adjacent-level degeneration. The authors concluded, Adjacent-level degeneration has not been adequately studied in a review of the available randomized controlled trials on this topic, and there is no clinical evidence of reduction in adjacent-level degeneration with the use of cervical arthroplasty. Moreover, cervical disc replacement is indicated in single-level degenerative disc disease. In this case, the patient has multi-level degenerative disease. In addition, long-term, adverse effects of arthroplasty materials, such as metallic and polymeric debris, are not known at this time. For the reasons provided, the requested procedure is not likely to be more beneficial for the patient's medical condition than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for growth hormone (GH) therapy, Genotropin 1.4 mg/0.25 mL syringe for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the patient has short stature and constitutional delay with an adult predicted height that is only 57 inches, which is 3 SDs below the mean. The patient meets standard U.S. Food and Drug Administration (FDA) criteria for treatment of idiopathic short stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of these criteria. Thus, the requested GH therapy, Genotropin 1.4 mg/0.25 mL syringe is supported as medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics and 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: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested a motorized scooter for treatment of his medical condition.  Findings:  The physician reviewer found the submitted documentation demonstrates this patient is limited in long distance mobility by arthritis in his knees and morbid obesity. However, he can ambulate independently with a four-wheel walker. In addition, he can complete in-home MRADLs independently with a four-wheel walker. Thus, the patient does not meet medical necessity criteria for a power wheelchair, as the patient can function independently with an assistive device.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested for cervical artificial disc replacement surgery for treatment of her cervical degenerative disc disease. Findings:  Three physician reviewers found that there is inadequate evidence to conclude that total cervical disc arthroplasty is more beneficial from a safety and efficacy standpoint than ACDF for the intermediate and long-term treatment of cervical disc disease.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested reimbursement for use of Alloderm acellular dermal matrix for complex fistula reconstruction repair for treatment of bronchopleural fistula.  Findings:  Two physician reviewers found that the patient has cystic fibrosis.  She developed a right bronchopleural fistula after right pneumonectomy.  This resulted in fungal empyema.  She has mixed connective tissue disease.  Her medical history is significant for pulmonary aspergillosis.  The patient underwent a combined thoracic and plastic surgery procedure which included placement of Alloderm acellular dermal matrix allograft to repair the bronchopleural fistula, with placement of a serratus anterior muscle flap and right latissimus dorsi muscle flap for coverage of the bronchopleural fistula and obliteration of the right pleural dead space.  The patient has requested reimbursement for use of Alloderm acellular dermal matrix for complex fistula reconstruction repair.  Alloderm is an acellular dermal matrix allograft used for repairs and reconstructions.  Alloderm is of particular use in infected or devitalized fields.  Its use has been documented in many applications, including tracheobronchial repairs and fistulas into the pleura and esophagus.  Tracheobronchial fistulas are difficult to manage, with life-threatening consequences if failure occurs.  The most common occurrence is after a right pneumonectomy.  This patient had a life-threatening bronchopleural fistula with fungal empyema.  The services provided were likely to have been more beneficial than other treatment alternatives in this clinical setting.  The use of Alloderm has been documented in multiple reports for use in complex tracheobronchial reconstruction.  In this patients case, use of Alloderm acellular dermal matrix for complex fistula reconstruction repair was likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested for the prescription medication Lipitor for treatment of his hypercholesterolemia.    Findings:  The physician reviewer found that there is no documentation provided demonstrating that Lipitor is medically necessary for this patient at this time. The most recent recommendation from the American College of Cardiology is to maximize the statin dose prior to using additional medications.  It is medically reasonable for the patient to attempt a trial of Zocor prior to treatment with Lipitor. If Zocor proves ineffective or has untoward side effects, the Health Plan should provide coverage for Lipitor.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a computed tomography (CT) scan of the left leg for evaluation of lumbar myofascial pain syndrome (MPS) of her left leg. Findings:  The physician reviewer found that the patient has requested a CT scan for evaluation of her chronic leg pain; however, there is limited medical literature to support this request. Imaging, especially computed tomography, has no significant role in the diagnostic workup for this patient. As noted by Childers and colleagues, Myofascial pain syndrome (MPS) is a painful disorder characterized by distinct sensitive spots in a palpable taut band of skeletal muscle fibers that produce local and referred pain. These palpable areas are referred to as myofascial trigger points (MTrPs) (Childers, et al). The symptoms are dull achy pain exacerbated by direct pressure over the trigger points. Unfortunately, there are no specific diagnostic or laboratory tests to confirm this diagnosis. As such, a CT scan is not likely to be clinically useful in the diagnosis and/or management of this patient's myofascial pain. All told, the efficacy of CT scans for evaluation of myofascial pain syndrome is not well established and therefore, the requested CT scan is not medically necessary in this patients case. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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

The parent of a 16-year-old male enrollee has requested a bilateral mastectomy for treatment of his gynecomastia. Findings:  The physician reviewer found that with regard to whether the proposed procedure is reconstructive in nature, based upon the documentation provided, the patients condition is not considered an abnormal structure of the body. Gynecomastia is quite common among adolescent males. It often occurs during puberty and most males experience natural regression of the breast tissue over time. The submitted photographs demonstrate grade I to III gynecomastia with little or no excess skin on either side. In sum, the submitted evidence does not demonstrate that the patients condition is so severe that it constitutes an abnormal structure of the body. Therefore, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning the medical necessity of the proposed procedure, the submitted evidence does not demonstrate that the patients condition results in a functional impairment. There is no medical record documentation of reports of pain that is refractory to standard therapies. In the absence of objective evidence of pain or discomfort that persists despite the use of conservative therapies (e.g., non-steroidal anti-inflammatory drugs or analgesics) or the existence of a physical functional impairment, the medical necessity of bilateral mastectomy is not established. All told, the documentation submitted in this case does not demonstrate the requested procedure is necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 13-year-old female who is reported to have Lyme disease and babesiosis. Treatment notes from February 2005 indicate the patients joint pain and fatigue were improved and a note from June 2005 states that babesiosis was resolved. Laboratory results from June 2005 were negative for IgM and IgG antibodies for Babesia microti. Findings from August 2005 revealed a negative IgM and equivocal IgG [1:20] titer. In September 2005, it was noted there had been a relapse of the babesiosis. The patients provider has prescribed 250mg of Zithromax twice a day. The Health Plan has denied authorization and coverage for Zithromax on the basis it is not medically necessary for treatment of the patients condition.Review of the submitted clinical information reveals no evidence of symptoms consistent with babesiosis or of the high antibody titers usually seen with an acute infection. The patient only has a single modestly elevated IgG titer for Babesia microti. There is no evidence of a positive blood smear or PCR. This single value is not diagnostic of babesiosis. Virtually all those who study and write about Babesia note that testing should be performed in the setting of clinical evidence of babesia infection, and that single abnormal values need to be repeated. In this case, the one isolated value is at the borderline of significance and is not diagnostic or even strongly suggestive of babesiosis. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Acthar Gel 80 Units daily for 5 days every month. The enrollee has was multiple sclerosis. He was seen by his neurologist and reported spasms of his right foot. Physical examination showed right arm weakness with no fine motor movements in the right hand, decreased range of motion in the right shoulder, and wrist drop after minimal exertion. The patent has right foot drop, right leg weakness, and uses a cane to walk. The patients neurologist reports his multiple sclerosis is progressive, he has debilitating exacerbations, and he has failed treatment with steroids, amantadine, and gabapentin. The neurologist prescribed Acthar Gel 80 units daily for 5 days per month and reports the patient needs this medication to speed the resolution of acute worsening exacerbations of multiple sclerosis. In the absence of relapses, Acthar Gel is not indicated. The patient has never been treated with any disease modifying agents. A letter of medical necessity describes the scientific rationale for Acthar Gel and mentions some negative effects the patient experienced in response to solumedrol, but does not address the use of Acthar Gel in the absence of multiple sclerosis exacerbations, or why the patient has not tried any disease modifying agents. Therefore, the medication Acthar Gel 80 units daily for 5 days per month is not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for acupuncture. Findings:  The physician reviewer found that although there is some peer-reviewed literature supporting a trial of acupuncture for chronic lower back pain, other articles reported the effectiveness of acupuncture for lower back pain remains unclear (van Tulder, et al; Cherkin, et al). Moreover, the use of acupuncture for the treatment of carpal tunnel is not supported in the peer-reviewed literature (OConnor, et al). In this case, the records submitted for review do not show evidence of objective functional improvement obtained with previous acupuncture sessions. The documentation does not include the specific gains obtained. 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 oriental 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.