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

A 52-year-old female enrollee has requested a back-up manual wheelchair for the treatment of her tetraplegia. Findings:  The physician reviewer found that this patients only mode of transportation is her power wheelchair, and when a breakdown occurs, as can reasonably be expected, this patient would not have any alternative form of transportation without a back-up manual wheelchair. Thus, the patient could be in a detrimental and hazardous situation with the risk of pressure sores if she were confined to bed during the breakdown of her power wheelchair. Additionally, the patient currently is transported via the familys van, although if that van ever needs maintenance or repair she would not be able to leave her home, whereas with the manual wheelchair her family could transfer her in a car. Therefore, a reclining manual backup wheelchair has been requested. In the past there was a period of time when the patient had a malfunction of her electric wheelchair, and she required a loaner reclining high-back wheelchair. The rationale provided by this patients treating physician, physical therapist and occupational therapist to support the medical necessity of a back-up manual wheelchair is appropriate and meets the standard of care. As noted by the patients providers, it is quite common over time for an electric wheelchair to malfunction or to need service. If this patients electric wheelchair was to malfunction, this would not be just a mere inconvenience to this patient, but would also create a risk of substantial complications of immobility if the patient had no option other than to stay in bed (skin breakdown, increased contractures, etc.). Easy and reliable access to a loaner wheelchair would be an alternative to purchasing a backup manual wheelchair for this patient. However, it is unlikely that a reclining high-back wheelchair would be available on a predictable basis if this patients power wheelchair were to unexpectedly require repair. Thus, the requested backup reclining high-back wheelchair is reasonable and not merely for the convenience of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female has requested magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer status post cyst removal and biopsy.  Findings:  Two physician reviewers found that the patient has a history of bilateral reduction mammaplasty, and right breast surgical excision. Magnetic resonance imaging (MRI) of the breast was last performed a year ago, with indication of routine follow-up due to increased risk of breast cancer. The patient has heterogeneously dense breasts on mammography. There is no documented family history of breast or ovarian cancer. The patients MRI was BIRADS-0, and the provider noted that both breasts require further evaluation with a second look ultrasound. On the left side, there was a 6 mm enhancing nodule retroareolar region. a month subsequent, a second look ultrasound was performed and stated that MRI findings correlated to benign nodules. A six month follow-up ultrasound was performed, which was BIRADS-2, and a routine mammogram was recommended in six months. The American College of Radiology (ACR) criteria recognize the increased sensitivity of MRI in the screening of high risk patients. Based on the records provided for review, the patient is not considered high risk. Therefore, the patient does not meet the ACR criteria for 20-25% risk and the requested MRI is not clinically indicated for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee requested authorization and coverage of a DEXA scan. The Health Plan denied the request indicating that the requested DEXA scan is not medically necessary for evaluation of the enrollees osteopenia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested DEXA scan is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old male enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of his stage IV colon cancer.  Findings:  Three physician reviewers found that current guidelines state that patients with oligometastatic colon cancer should be treated aggressively including local treatment to each liver lesion in the form of surgery or radiation (Benson, et al). The records indicate that this patient underwent surgery for the hepatic lesions and the surgeon determined that the third lesion could not be completely resected. Therefore, SBRT is considered appropriate in this clinical setting because the remaining hepatic lesion cannot be entirely removed by surgery. There are adequate prospective studies demonstrating the efficacy of stereotactic body radiotherapy in this setting (Schefter, et al; Katz, et al). Thus, the requested services are likely to be more beneficial for treatment of the patients condition than other standard therapies.
Appeal type: Urgent Care
Decision: Upheld

A 53-year-old female enrollee has requested emergency services for the 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. This patient was experiencing an acute exacerbation of her chronic restless leg syndrome. The submitted medical records do not document that the patient was experiencing extreme pain. She had not sustained any injury. Since the patient had a long-standing history of restless leg syndrome, she would have reasonably known that her symptoms did not represent a danger to her health. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. She could have been evaluated on a routine basis for a medication adjustment. Because this patients symptoms were not sudden in onset and she had not sustained an acute injury, her symptoms do not meet criteria for an emergency medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine without dye and MRI of the thoracic spine. Findings:  The physician reviewer found that he patient is currently asymptomatic. In addition, there is no detailed neurological examination demonstrating any red flags such as weakness or neurologic deficit. Further, there is no recent history of trauma, infection, or malignancy to support an indication for MRI. The records do not include abnormal findings on electromyography (EMG) or x-ray of cervical or thoracic spine. Absent current concerning symptoms or neurological deficit, there is no indication for MRI of the cervical or thoracic spine without a trial of conservative management including physical therapy. For these reasons, the requested MRI of the cervical spine without dye and MRI of the thoracic spine are not medically necessary for evaluation of this patients neck pain. Final Result: The reviewer determined that the requested services are 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 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: Overturned

A 34-year-old female enrollee has requested the medication Lyrica for the treatment of her fibromyalgia. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has fibromyalgia, which has failed to respond to various standard medication trials including antidepressants and Neurontin. Neither Neurontin nor any antidepressant has specific FDA approval for treatment of fibromyalgia, though standard practice usually includes trials of these agents. However, among these agents, any choice is arbitrary. Based on the evidence provided, this patient has already failed trials of Neurontin and antidepressants (Zoloft, Wellbutrin, and Trazadone) and has shown a beneficial response to a trial of Lyrica, which is the only agent approved by the Food and Drug Administration for treatment of fibromyalgia.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee requested authorization and coverage of extracorporeal shock wave treatment (ESWT). The Health Plan denied the request indicating that ESWT is not medically necessary for the treatment of the enrollees plantar fasciitis.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee has requested authorization and coverage for the medication methadone. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain, degenerative neck and back disease. At issue in this case is whether the requested methadone is medically necessary for treatment of the enrollees medical condition.The CDC guidelines do not recommend opiates for chronic pain in patients with a history of drug abuse. The Federation of State Medical Boards similarly, does not support the use of chronic opiates in a patient with a substance abuse history. Therefore, the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  speech therapy, at a frequency of two sessions per week for one hour each session for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of 37%, with delays in her social interaction. Speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Extensive review of the literature, including meta-analysis by Law, et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. Statistically greater improvement was found with intensive direct speech and language therapy delivered by speech and language therapists over an eight month period when compared to no intervention or nursery-based intervention. The provided medical records and review of the above peer-reviewed medical literature demonstrates that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested balloon sinus ostial dilation for treatment of his chronic sinusitis.  Findings:  Three physician reviewers found that balloon sinuplasty has not been shown to be more beneficial than available standard interventions for patients with refractory sinusitis. Melroy and colleagues noted that balloon dilating catheter should be considered an instrument that can be used in sinus surgery alongside standard instrumentation or as a stand-alone device. However, this patients records do not include adequate documentation of an indication for surgery or that conservative measures have been exhausted. Given the lack of peer-reviewed medical literature, the requested procedure is not likely to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment with an anatomic and clinical pathologist. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. Cysts or tumors of the jaws may present in a variety of ways.  One way tumors are identified is through persistent pain. Another method is through radiographic evidence.  The patient has been treated by several providers, has had surgery and yet, she still experiences jaw pain. This patient has well documented pain and radiographic evidence demonstrating possible progression of the lesion. The patient was treated with several therapies without resolution. It is medically reasonable and necessary to be certain a tumor of the jaw is not present, in this patients case.  As such, it is equally prudent to have a second opinion to determine that this patient has an inflammatory process and not something neoplastic. Therefore, for the reasons stated above, the requested services are medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anatomic pathology 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 62-year-old male enrollee has requested brain imaging, positron emission tomography (PET) (78608) for evaluation of his medical condition. Findings:  Two physician reviewers found that there is sufficient medical literature supporting the use of a PET scan in this clinical setting. This patient has a variety of symptoms that are relatively mild and do not yet meet criteria of dementia, but suggest the possibility of early frontotemporal dementia (FTD). PET scan has been well documented to be helpful in making the diagnosis of FTD and differentiating it from Alzheimers. This patient has underlying obsessive-compulsive disorder (OCD) tendencies, high anxiety and life stress issues and given the unclear diagnosis after standard testing and two neurologic opinions, the requested brain imaging PET scan is likely to be more beneficial in determining a diagnosis and developing an appropriate care plan than other standard testing. Therefore, based on the peer-reviewed literature and medical evidence submitted the requested PET scan is likely to be more beneficial than standard medical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan. The assessment of disease burden and therapeutic response in this patient with metastatic renal cell carcinoma is critical to her care and effective decision-making. The patient has extensive disease with soft tissue and bone lesions. She is not able to continue with contrast enhanced computed tomography (CT) imaging due to an iodine contrast allergy. CT imaging without contrast would not be useful for appropriate care of this patient. PET imaging has demonstrated effective detection of clear cell renal cancer metastases comparable or superior to contrast CT imaging. In one publication comparing PET/CT imaging to contrast CT imaging, PET detected all of the sites of distant metastasis revealed by CT, as well as eight additional metastatic sites, leading to an accuracy of 94% versus 89% for CT. All told, the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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: Overturned

A 61-year-old female enrollee requested authorization and coverage of a consultation for gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested consultation is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest (HCPCS K0606). The documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with a left ventricle ejection fraction (LVEF) less than or equal to 35%. This patients LVEF was 30-35%. The recommended timing of placement of a wearable cardioverter defibrillator based on guidelines from the American College of Cardiology (ACC), American Heart Association (AHA), and the Heart Rhythm Society (HRS) is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of congestive heart failure with a low ejection fraction. This patient underwent follow up echocardiography beyond the 40-day window and had an improved LVEF of 50-55%. Given the improvement in the patients LVEF, the placement of the LifeVest was appropriate for 40 days, as the patients LVEF would no longer have met the criteria for a wearable cardioverter defibrillator by that time. Therefore, the Zoll LifeVest (HCPCS K0606) provided for 40 days was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Zoll LifeVest (HCPCS K0606) provided for 40 days was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. The peer-reviewed literature continues to demonstrate positivism for TMS, while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama, et al). In addition, TMS is approved by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. The patient has trialed appropriate psychotropic medications and previously pursued a course of ECT, which was poorly tolerated. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS is an appropriate treatment and is consistent with good medical practice. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness, and therefore, medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 pills in 30 days of azithromycin 250 mg for treatment of the enrollees pustular rosacea. Findings:  The physician reviewer found that There is support in the medical literature for the requested medication quantity in this clinical setting. The tetracycline family of oral antibiotics is typically used for the treatment of inflammatory rosacea, even for extended courses.  However, the patient had a severe reaction when previously prescribed minocycline.  Consequently, further use of the tetracycline should be avoided. This patient has previously tried azithromycin with good effect. Given the circumstances, coverage for 30 pills in 30 days of azithromycin 250 mg is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication quantity 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 dermatology 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.