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

The parent of a four-year-old female enrollee has requested a feeding therapy program for the treatment of the residual effects of the enrollees premature birth. Findings:  Three physician reviewers found that this patient appears to be doing well despite her multiple medical problems. Pertinent to feeding, she has had remarkable success with the intensive feeding therapy program she has participated in during the past several months. The patients growth chart demonstrates acceleration from less than the 3rd percentile to about the 25th percentile.  This result is comparable to a surgically placed feeding tube. Thus, in this case the feeding therapy program has been both efficacious and efficient in correcting the patients poor nutrition and poor weight gain without surgical intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested laboratory testing for evaluation of her medical condition. Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this patients case.  A review of the medical literature finds that the predictive value of the presence of various mutations for directing the duration of anticoagulation is low.  There is a lack of trials comparing routine and prolonged anticoagulant treatment in patients who test positive for various mutations.  Given this lack of evidence, testing for such genetic variations to guide duration of anticoagulant therapy is not supported by the medical literature.  Thus, laboratory testing performed was not likely to have been more efficacious than other modalities.   Final Result: Three physician reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: All three reviewers are board certified in internal medicine and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a nine-year-old male who was evaluated by his podiatrist from early March 2003 through April 2003. Numerous diagnoses were made including fasciitis, flat feet, varus, and abnormal pronation. During an evaluation in February 2004, the patients physician noted the patients feet were turning inward and the patient had pain in his heels. A podiatry consultation was recommended. The Health Plan has denied authorization for the consultation on the basis that it is not medically necessary.There are numerous differential diagnoses for heel pain including but not limited to plantar fasciitis, infra-calcaneal bursitis, apophysitis, stress fracture to calcaneus, calcaneal bone cyst, calcaneal bone tumor, and avascular necrosis of calcaneus. In light of the extensive differential diagnoses for heel pain an extensive podiatry evaluation of the patient is medically reasonable and appropriate. It is possible that the patients heel pain and flat feet are mutually exclusive. A podiatry evaluation is needed to determine the etiology of the patients pain. Therefore, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested for radiofrequency ablation (RFA) for treatment of her renal mass. Findings:  Two physician reviewers found that radiofrequency ablation involves the local application of radiofrequency thermal energy to a tumor.  A high frequency alternating current moves from the tip of an electrode into the surrounding tissue, resulting in heating and tissue necrosis around the electrode.  Increasing data support the safety and efficacy of radiofrequency ablation for small renal tumors.  Although results are encouraging, studies on this treatment are deficient and provide only short follow-up. There are no randomized controlled comparisons to surgical resection and no comparison of complication rates. Due to these factors, the advantage of radiofrequency ablation over existing treatments for renal cell carcinoma is not established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested sacroiliac joint fusion of the left side for treatment of her left sacroiliac joint pain.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. SI joint fusion is not the standard of care for SI joint disorders. In addition, the medical records submitted for review do not demonstrate that this patient has had SI joint trauma, tumor or infection. Moreover, SI joint fusion remains controversial for the treatment of chronic low back pain. More long term outcomes studies are needed to establish the safety and efficacy of SI joint fusion. In sum, SI joint fusion of the left side is 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 orthopedic 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 platelet rich plasma (PRP) injection of the left lateral epicondyle. Findings:  The physician reviewer found that there is sufficient medical literature supporting the use of platelet rich plasma for chronic lateral epicondylitis resistant to other conservative treatment. Medical studies suggest platelet rich plasma to be a safe and effective therapy for tennis elbow. A study  evaluated to a total of 230 patients with chronic lateral epicondylar tendinopathy. All patients had failed conservative conventional therapy. At 24 weeks clinically meaningful improvements were found in patients treated with platelet rich plasma compared with an active control group. Similarly, another study performed a retrospective study of patients with chronic lateral epicondylitis treated by a  surgical technique (50 elbows) or platelet rich plasma (60 elbows). Outcome was evaluated with visual analog scores, Mayo elbow scores, and grip strength measurements. The platelet rich plasma group was reported to be better for short and midterm pain relief and functionality. The improvement was 83% in the platelet rich plasma group. In this case, the patient has chronic elbow tenderness over the lateral epicondyle and pain with resisted wrist extension with manifestations of lateral epicondylitis tendinopathy. Platelet rich plasma injection for chronic lateral epicondylitis upon failure of conservative treatment has been established as 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 procedure 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 reviewers 1, 2 & 3 are  board certified in orthopedic 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Gamunex-C solution (intravenous immunoglobulin) 40 g/400 mL, three days every four weeks. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who has a history of autoimmune disease.Findings: There is support in medical literature for the medical necessity of the services at issue in this clinical setting. Studies have demonstrated the clinical benefits of IVIG treatments in improving pregnancy outcome and downregulation of the peripheral blood NK cells. Additionally, the medical literature indicates that post-conception IVIG treatment significantly improves reproductive outcomes in women with elevated CD56+ NK cells with pregnancy. According to the submitted clinical information, this patient is diagnosed with elevated level of NK cells and CD19+/5+b-1 cells in the peripheral blood. She is also diagnosed with recurrent pregnancy loss and antiphospholipid antibody disorder.  Based on the documentation provided and the medical evidence, this patient would benefit from continued IVIG treatment.  Therefore, Gamunex-C solution (IVIG) 40 g/400 mL, three days every four weeks were and are medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were and 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 allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a seven-year-old female with microcephaly, mental retardation and cerebral palsy with spastic quadriplegia. A detailed medical history was not submitted. The record indicates the patient was evaluated for outpatient physical therapy (PT) and participated from February 2006 to March 2006. She has also been evaluated for home therapies. The parent has requested that PT and OT be provided through a Home Health agency. The Health Plan denied his request based upon a determination that home therapies are not medically necessary.Concerns regarding the adequacy of the PT the patient has received thus far are valid. It is obvious from both the outpatient PT evaluation and the Home Health PT evaluation that neither therapist is experienced in treating children with cerebral palsy. A pediatric therapist experienced in treating patients with cerebral palsy is essential for this patient. However, there is no obvious need for the these therapies to be provided in the home environment. The Home Health aspect of the therapies appears to be a matter of convenience. The record did not include much medical history and the recent neurological evaluation and report were very limited. The need for Home Health PT and OT cannot be fully assessed without a complete medical history. Nonetheless, there is no indication of a medical condition that places the child at severe cardiopulmonary risk or an immunodeficiency creating a risk of infection in the outpatient setting. As there is no evidence that outpatient therapies would create an additional health risk for this patient, outpatient OT and PT therapy provided by therapists with pediatric experience would meet her medical needs. The therapists should establish functional goals that are measurable and progress to goals should be monitored by a pediatric physiatrist or pediatric orthopedist experienced in the treatment of patients with cerebral palsy. OT and PT evaluations should be completed at six month intervals to ensure the patient is making functional progress. If an evaluation does not document functional gain, transition to a monitored home program would be appropriate. In all likelihood, the patient would qualify for services at a Medical Therapy Unit through California Childrens Services, as eligibility is not income-based.Based upon the information set forth above, I have determined the requested Home Health therapies are 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 authorization and coverage for Arthroflex for treatment of the enrollees left Achilles tendinosis. Findings: The physician reviewer found that there are limited studies available addressing clinical outcomes of arthroflex in tendon augmentation or in any other application. Barber and colleagues reported that their study suggested that GraftJacket augmented Achilles tendon repair could withstand a more aggressive rehabilitation program, potentially decreasing ankle stiffness and allowing earlier return to full activities. However, this study is of limited benefit given the small number of Achilles tendons evaluated. All told, the requested Arthroflex is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The three physician reviewers determined that the requested service is 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 orthopedic 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested Botox injections for treatment of her chronic migraines.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature supports the use of Botox in this clinical setting. A review of the medical records indicates a diagnosis of chronic migraine. The definition of chronic migraine requires 15 or more headache days a month with at least eight being migrainous. While a migraine by definition lasts at least four hours, it is still defined as migraine if the headache has features of migraine, and is aborted by a migraine specific treatment such as Imitrex, even if it does not last a full four hours. Also, acute treatment has a goal of complete headache relief within two hours. The medical records document that the patient has more than 14 headaches days a month, most of which are migrainous. Although the patient has other headaches that are not migrainous, that does not change the diagnosis of chronic migraine. The medical literature cited above supports the safety and efficacy of Botox injections for the treatment of chronic migraine. Therefore, Botox injections were and are likely to be more beneficial than standard medical therapy and are appropriate treatment for the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old female enrollee has requested  for therapy with a mental health provider who specializes in adoption issues for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that a review of the peer-reviewed medical literature suggests that there is much disagreement about the diagnosis and treatment of RAD. Overall, there is no clear gold standard for the treatment of this disorder. The article by Hanson and Spratt noted that, in the recent years, there has been an increase in the number of children diagnosed with RAD. There is considerable disagreement about what this entity actually entails and, in particular, what types of assessments and interventions to use with these children and families. The author expressed concern regarding the consequences of the RAD diagnosis to be the emergence of novel treatments that lack a sound theoretical basis or empirical support, and may potentially be traumatizing and dangerous to the child. The article by Hardy states that, Although evidence for the effective treatment of children with attachment disorders is minimal and inconclusive, the two major perspectives, developmental psychology and neuropsychoanalysis, offer guidelines. There is a lack of support for treatment of this patient with a specialist in attachment disorders.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage of injectable growth hormone for the treatment of growth hormone deficiency.  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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for home nursing care totaling 16 hours per day, seven days a week for a total of 112 hours per week. The records document that this patient has congenital myasthenic syndrome, a cause of neuromuscular dysfunction. He has chronic respiratory failure and dysphagia that requires a feeding tube. The documentation suggests that the patient has been medically stable. He does not have any complications with his tracheostomy or feeding tube and he has not experienced an acute exacerbation of a chronic medical problem. He is able to attend school and attend to activities of daily living. The Health Plan has approved eight hours a day of skilled home health care for pulmonary management. Given his medical stability, eight hours of day of home nursing care is an appropriate amount of services. He does not require skilled home health for custodial care or daily skilled care for feeding tube and medication administration. For these reasons, the requested home nursing care totaling 16 hours per day, seven days a week, for a total of 112 hours per week was not and is 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 internal medicine with expertise in skilled nursing facilities 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 fertility preservation services including intracytoplasmic sperm injection (ICSI), oocyte fertilization, embryo development, and subsequent embryo cryopreservation with PGD screening. Sperm and embryo cryopreservation as well as oocyte cryopreservation are considered standard of care for patients who plan to undergo treatment for cancer, which is expected to result in iatrogenic infertility. Fertility preservation options in females depend on a patients age, diagnosis, type of treatment, presence or participation of a male partner and patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries. The records provided for review document that this patient plans to undergo treatment with chemotherapy and radiotherapy. Thus, she is at very high risk of developing ovarian failure due to the gonadotoxic treatment modalities. In addition, this patient may require removal of her ovaries surgically to decrease her risk for ovarian cancer. The standard of care is to proceed with in vitro fertilization (IVF) and oocyte or embryo cryopreservation. Given the presence of a BRCA mutation in this patient, performing PGD on embryos and selecting non-affected embryos to transfer is appropriate to help prevent the birth of a child affected with a BRCA mutation. For these reasons, the requested fertility preservation services including ICSI, oocyte fertilization, embryo development, and subsequent embryo cryopreservation with PGD screening are medically necessary for treatment of this patient. 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 obstetrics and gynecology with subspecialty certification in reproductive 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: Urgent Care
Decision: Overturned

A 36-year-old male enrollee has requested surgical services for treatment of his corneal perforation.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patient was experiencing an emergency medical condition on the date indicated. Perforation of a corneal ulcer is considered a medical emergency in the practice of ophthalmology. Perforation can lead to infection, irreversible structural damage and retinal/choroidal detachments. Emergency corneal grafting is medically indicated and necessary to prevent these complications from ensuing. Thus, a prudent layperson in this situation would have sought immediate medical attention on the date indicated.