Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The pulmonary function testing performed was not necessary for treatment of an emergency medical condition. Pulmonary function testing is not supported in the peer-reviewed literature as an emergent or urgent diagnostic test in the management of Raynauds syndrome and scleroderma. In this case, there was no emergent medical condition noted in the records submitted for review. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator.  Findings:  Three physician reviewers found that the patient has a history of obstructive sleep apnea (OSA). He underwent a polysomnogram (PSG) on 8/16/15 and it revealed an apnea hypopnea index (AHI) of 61. He had a body mass index of 35. By sleep endoscopy, there was complete anterior to posterior collapse of the velum, complete mixed collapse of the hypopharynx and posterior excursion of the tongue base. He was intolerant to continuous positive airway pressure (CPAP). The provider discussed options for implantation with a hypoglossal nerve stimulator. The medical literature does not support the superior efficacy of the requested services in this clinical setting. OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. CPAP has demonstrated excellent efficacy and low morbidity, and long-term adherence rates approach 50%. After decades of trials with hypoglossal nerve stimulation, the results of these studies were recently published. The STAR trial demonstrated that hypoglossal nerve stimulation led to improvements in objective and subjective measurements of the severity of OSA. However, the STAR trial did not involve patients with AHI less than 20 or greater than 50. Patients with BMI greater than 32 were not included in the study. This patients AHI was 61 and he had a BMI of 35. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a panniculectomy.At issue is whether the requested panniculectomy is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?According to the American Society of Plastic Surgeons, a panniculectomy should be considered a reconstructive procedure when performed to correct or relieve structural defects of the abdominal wall, improve skin health within the fold beneath the pannus, and/or help improve chronic low back pain due to functional incompetence of the anterior abdominal wall. Moreover, researchers state that panniculectomies have been shown to be of benefit for the quality of life of patients. In this case, the patients pannus hangs below the pubis and has caused intertrigo. The patient has been prescribed steroid creams and antifungal medications. There is adequate documentation in the medical records indicating that these rashes and fungal infections are persistent despite appropriate hygiene as well as the antifungal and steroid creams. Therefore, the requested panniculectomy is medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The patients condition is an abnormal structure of the body as a result of massive weight loss after a medically necessary procedure. The pannus has resulted in chronic fungal infections. The requested surgery will eliminate the pannus and help avoid fungal infections. The surgery will provide more than a minimal benefit, as it should eliminate the rashes, bleeding and burning sensation. Additionally, the procedure is expected to restore function. Therefore, the requested panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested service is 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a microsurgery lymphovenous bypass procedure. Garza and colleagues describe lymphaticovenular anastomosis or lymphovenous bypass as, A surgical procedure where lymphatic vessels in a lymphedematous limb are connected to nearby small veins and venules using microsurgical and super-microsurgical techniques. This allows the clearance of lymphatic fluid from the affected limb, by utilizing the venous system, which has the capacity to easily accommodate the extra fluid volume, as an outflow. A direct surgical connection is created between the overloaded lymphatic channels, proximal to the site of the lymphatic obstruction, and nearby venules. The authors further note, Numerous studies have been published which show improved symptoms and as much as 61% reduction in volume difference of the affected limb after lymphaticovenular anastomosis at one year. Schaverien and Coroneos note, Observational case-control and cohort studies support the efficacy of lymphovenous bypass and vascularized lymph node transplantation for lymphedema in reduction of limb volume and episodes of cellulitis. The available literature supports favorable limb volume reduction outcomes for both orthotopic and heterotopic lymph node flap transfer in both the upper and lower extremities. Pereira and colleagues report that lymphovenous anastomosis is an effective treatment option to reduce the volume in the affected limb and to improve symptoms involved. In this clinical setting, the use of the requested service is supported by current medical literature in treating this patients condition. Therefore, the requested microsurgery lymphovenous bypass procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested microsurgery lymphovenous bypass procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment 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 plastic surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in general surgery and in vascular surgery 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: Upheld

The parent of a nine-year-old male enrollee has requested speech therapy for the treatment of his autism. Findings:  The physician reviewer found that speech therapy is medically necessary when addressing an illness, injury, surgery or congenital abnormality. The medical records do not indicate that the patients language disorder is related to such a condition. Speech therapy in this clinical setting is educational in nature, and as such, is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old female with a long history of alcohol dependence and pain medication abuse. The patient was admitted to a substance abuse residential treatment facility in January 2006. Admitting diagnoses included alcohol dependence, opioid mood disorder, and personality disorder  not otherwise specified. She remained at a residential level of care until February 2006. The Health Plan indicates a residential level of care was not medically necessary for treatment of the patients condition.Review of the submitted records reveals no need for treatment in a 24-hour setting. The patient was experiencing no withdrawal symptoms and her vital signs were stable. She was drug seeking and non-compliant with program rules. There was no substance abuse assessment noted in the records, just a reference to substance abuse. There was no evidence of failure at a lesser level of treatment and no evidence of prior participation in a 12-step program in her community. As such, the patient did not meet criteria or standards of care for residential treatment level of care. Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the mixing and preparation of antigens for immunotherapy injections. In this case, the provider reported a plan to monitor the patient and to see the patient in one year following preparation of allergy immunotherapy. The patient received vials for subcutaneous immunology therapy. The records do not document weekly injection showing the prepared serums were to be administered under the supervision in a professional setting, as is generally required by practice guidelines. Administration of allergy immunotherapy at home, and not at a professionals office is a deviation from standard therapy in this clinical setting. Therefore, the mixing and preparation of antigens for immunotherapy injections was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the mixing and preparation of antigens for immunotherapy injections was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in allergy and immunology 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: Upheld

A 34-year-old female enrollee has requested acupuncture for treatment of her abnormal menses. Findings:  The physician reviewer found that this patient reports improvement of abnormal periods that she attributes to acupuncture.  An extensive review of the literature reveals many recommendations for evaluation of abnormal bleeding, and a number of available treatments, which do not include acupuncture. Other treatments for abnormal menses (in addition to oral contraceptives) include progesterone therapy, the Mirena IUD and endometrial ablation (if fertility is no longer desired). There is a lack of studies comparing acupuncture to placebo treatment for this indication. Due to the lack of outcome data to support the use of acupuncture for this patients medical condition, the medical necessity of acupuncture in this setting is not established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested high-dose intravenous immunoglobulin therapy for the treatment of her spontaneous abortions. Findings:  Three physician reviewers found that current literature and meta-analyses indicate very poor results with IVIG for recurrent pregnancy loss, making its use inappropriate for this indication. In addition, the only patients in whom there is a report of possible improvement are those with secondary recurrent miscarriage, or miscarriages following a successful pregnancy. In primary recurrent miscarriage, where a woman has not had a prior successful pregnancy, treatment with IVIG has shown no improvement compared to placebo therapy. This patient had primary recurrent miscarriage. There is a current multicenter study looking at IVIG for secondary recurrent miscarriage to further assess possible use, but results have not yet been published. The researchers specifically excluded women with primary recurrent miscarriage because studies to date had failed to indicate any utility in those patients. Thus, IVIG was not likely to be more beneficial for treatment of the patients medical condition, and studies to date show it has no more efficacy than placebo.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 15-year-old male enrollee has requested for cognitive rehabilitation therapy for treatment of the enrollees brain injury. Findings:  The physician reviewer found that review of the submitted therapy evaluation and daily progress notes reveals that the objectives as written in the evaluation are not measurable. There is no mention of the frequency of therapy or short- or long-term goals. Nor is there evidence of significant functional gains. Furthermore, there is no literature to support the benefit of cognitive rehabilitation therapy four years following traumatic brain injury.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested a treatment plan the enrollees autism.  Findings:  The physician reviewer found that Hayward reported on a study of 24 patients that compared the hours spent in clinical intervention with all treatment personnel and an intensive parental managed model with intensive supervision only. The author concluded that the division of hours did not make a significant difference while the total hours of combined treatment was effective. All told, the ABA treatment plan proposed is not medically necessary for treatment of the patients autism. Appropriate in-network services have been authorized by the Health Plan. The in-plan providers can transition the patient into an age appropriate program to meet his individual needs.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested authorization and coverage for cataract surgery.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  This patient reported that his vision impacts daily activities.  He reported difficulty driving at night and reading text on the television.  Although this patient exhibits cataract on examination, the records show that the patients vision loss is primarily related to an uncorrected refractive error.  The patients symptoms are likely correctable with glasses.  Refractive lens exchange was offered as a means to reduce the patients need for glasses.  The medical records do not demonstrate that the patients cataract is causing the patients symptoms.  All told, the requested cataract surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral lumbar sacral facet joint injections at L3-S1. An updated review regarding facet joint injections from the American Society of Interventional Pain Physicians (ASIPP) noted that there is adequate evidence in selecting patients for facet joint nerve blocks at least three months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment (Manchikanti, et al.). Manchikanti and colleagues also stated that, The evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. On review of the medical literature, the best evidence for the use of medial branch blocks is for diagnostic purposes in anticipation of a radiofrequency ablation procedure (Cohen, et al.). In this case, the patients most recent reported lumbar MRI demonstrated fusion along with signs of foraminal stenosis at the L3-4 and L4-5 areas. The providers notes outline a previously completed cervical medial branch block. However, there is a lack of documentation from the provider regarding the patients back pain complaint, pain intensity scale, referral patterns or previous response to the injections to support an indication for facet joint injections. All told, the requested bilateral lumbar sacral facet joint injections at L3-S1 are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 monitored anesthesia care for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia care was not medically indicated 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 board certified in anesthesiology 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.