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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fetal echocardiography with doppler color flow velocity mapping services. Findings:  The physician reviewer found that  guidelines and medical literature supports evaluation with an anatomic scan including standard cardiac anatomy in the latter part of the first trimester for all pregnancies. Data suggest that a subsequent separate fetal echocardiography is recommended when there is an increased risk of cardiac anomalies. As noted by Copel and colleagues, The optimum gestational age for screening for structural fetal cardiac anomalies is 18 to 22 weeks of gestation. Fetal cardiac anatomy can be visualized well at this stage of pregnancy, a complete fetal anatomic survey can be performed, and there is time for further evaluation. Per the authors, A standard obstetric ultrasound examination includes assessment of the four chambers and ventricular outflow tracts of the fetal heart. The inclusion of views of the outflow tracts increases the likelihood of identifying conotruncal anomalies. The authors concluded that this work-up is consistent with the recommendations for sonographic screening of the fetal heart from the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM). In this case, the patient underwent evaluation with a standard ultrasound. Subsequently, her provider recommended a fetal cardiac echocardiography given the elevated risk of fetal cardiac anomalies. Indications with a high-risk profile include maternal pregestational diabetes mellitus or diabetes mellitus diagnosed in the first trimester and pregnancy conceived by assisted reproduction technology. This patient became pregnant through use of assisted reproduction technology. Given these findings, the ultrasound with fetal echocardiography with doppler color flow velocity mapping services were medically necessary for evaluation of this patient.  Final Result: The reviewer determined that the services at issue were 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A male enrollee requested urgent care services on an emergent or urgent basis. Findings:  The physician reviewer found that based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition. The patient could have contacted his primary care physician and been evaluated as a routine medical care visit. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part, and the patient did not meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hyalgan injection series.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of lasting relief from viscosupplementation in the past, with the relief lasting one year. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including physical therapy and platelet-rich plasma injections. The alternative is a total knee arthroplasty. Therefore, the requested Hyalgan injection series is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested the brand name drug Neurontin, the brand name drug Ultram, and medicinal marijuana for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this clinical setting.  The current standard of care for chronic back pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy and injections to help reduce pain.  In regards to medication, the peer-reviewed literature advocates non-steroidal anti-inflammatory medications as the gold standard for non-radicular and non-neuropathic axial pain.  Ultram is a mild opioid which has the potential for dependence and abuse.  In a retrospective study by Baron and McDonald, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Further, although gabapentin (Neurontin) is efficacious for treatment of neuropathic and post-surgical pain, non-steroidal anti-inflammatory medications are superior for the treatment of chronic axial back pain, such as is involved in this case. Moreover, there is a lack of evidence demonstrating that medicinal marijuana is more effective in this setting than non-steroidal anti-inflammatory medications. The current medical evidence does not support the requested medications for the treatment of this patient.  All told, the brand name drug Neurontin, the brand name drug Ultram and medicinal marijuana are not medically indicated.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.The urgent care services provided were necessary for treatment of an emergency medical condition. The patient presented with an acute ankle injury. He had sustained an inversion injury the day prior and could not walk without the assistance of a cane. Physical exam noted swelling, ecchymosis, and tenderness. Trauma sustained when twisting a foot on a step can range from minor sprains to fractures or dislocations. The most severe and often missed injury is a Lisfrancs fracture/dislocation. Failure to recognize this in a timely fashion may lead to chronic pain and instability. Symptoms of ankle pain, swelling, and discoloration the day following trauma meets the criteria for an emergency medical condition. Therefore, the services provided on date of dispute  were necessary for treatment of an emergency medical condition.  Final Result: The reviewers determined that the enrollee received emergency medical services the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer number one is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Otezla tablets. The enrollee has plaque psoriasis. A progress note reports the enrollee has symptoms of redness, itching and pain, and that she had been using calcipotrine cream, 0.05 percent, as needed. The progress note documented psoriasis to the enrollees back and knees. At a follow-up, the physician prescribed Enstilar for the enrollee. A subsequent note reports the enrollee described her symptoms as worsening and that she had not seen any improvement from the Enstilar. The enrollee reported wanting to start biologics or Otezla. The physician noted the enrollee would require laboratory testing prior to starting Cosentyx. The physician provided the enrollee with an Otezla starter pack. In order to be approved for Otezla, the enrollee must try, fail, have a contraindication to, documented adverse effect to or provide any clinical reason why the preferred available standard of care medications, such as methotrexate, psoralen and ultraviolet A, ultraviolet B, cyclosporine, or acitretin, cannot be used. The enrollee does not have contraindications that are sufficient to avoid preferred therapies.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested authorization and coverage of scar revision for the treatment of scars and discoloration from prior sclerotherapy.  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 upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

 A female enrollee requested the  EasyStand Evolv Stander (E1399) for medical treatment of her multiple sclerosis.  Findings:  Two physician reviewers found that the current medical literature has not established the superior efficacy of the requested equipmentThe current literature is not adequate to demonstrate its utility, benefit, or safety in this clinical setting.  The studies that have been done have been small, and several of these studies have demonstrated no benefit.  In sum, the requested EasyStand Evolv Stander (E1399) is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for gene panel testing.  Testing for common recessive genetic disorders during pregnancy is beneficial to the patient because it allows the patient to make important medical decisions in the event that she is a carrier for a serious recessive genetic disease. If the patient is positive for a particular mutation, then her partner can also undergo testing. This allows for determining the potential to have an affected offspring with a serious genetic disorder.  Having this information is certainly more beneficial than not having the information. Moreover, the American College of Obstetricians and Gynecologists (ACOG) and other professional reproductive medical organizations support carrier testing in this clinical setting. For this patient, the provider recommended genetic carrier testing, including evaluation for SMN1 and SMN2, consistent with the ACOG recommendations. Therefore, the gene panel testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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 parent of a 3-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism and developmental speech and language disorder.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a well-documented record of substantially improving motor, verbal, and social interactive skills in autistic children. According to Myers, The effectiveness of ABA-based intervention in ASDs has been well documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. Multiple controlled trials have confirmed that ABA therapy is the treatment of choice for children with autism (Turner et al). Given that the submitted documentation demonstrates the patient has been diagnosed with autism, ABA therapy is medically appropriate and necessary for treatment of his condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for cryoablation of left occipital nerve. As noted in the medical literature, occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Occipital nerve blocks are supported for diagnostic purposes but are not supported for therapeutic treatment as there is a lack of long-term benefit supported by the current peer-reviewed medical literature. A report noted there was no long-term improvement of chronic migraine type headaches with use of occipital nerve block. Another report reported that greater occipital nerve blocks do not reduce the frequency of moderate-to-severe migraine days in patients with episodic or chronic migraine compared to placebo. There was no long-term improvement of headache of chronic migraine type with use of occipital nerve block. For these reasons, the medical records do not indicate that cryoablation of the left occipital nerve is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that cryoablation of the left occipital nerve is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology and is 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: Upheld

A 54-year-old female enrollee has requested breast surgery (bilateral breast implant removal, bilateral capsulectomy, bilateral breast reduction and formal mastopexy) for the treatment of her breast deformity. Findings:  The physician reviewer found that the American Society of Plastic Surgeons position paper on reoperation for implants placed for cosmetic augmentation, the medical necessity criteria for reoperation includes (1) a broken or failed implant, (2) infection, (3) implant extrusion, (4) siliconoma or granuloma, and (6) interference with the diagnosis or treatment of breast cancer. Consideration is also given when pain is a factor. In this instance, there is no mammography or CT evidence of silicone granulomas. The records do not document painful capsular contracture or other functional problems. The operative note did not describe ruptured implants. It appears that the breast surgery was performed to improve the appearance of the breasts.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of her hepatitis C. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive, genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 2 regardless of fibrosis stage.  For these reasons, Sovaldi for is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 Supartz injections in both knees. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. However, there is a lack of studies supporting a role for hyaluronic acid injection more frequently than six months. The patient underwent injections and presented to his provider three months later, requesting repeat Supartz injections. This suggests that the injections completed did not result in substantial lasting relief for this patient. Based on the foregoing discussion, the Supartz injections in both knees are not likely to be more beneficial for treatment of the patients knee pain with osteoarthrosis than any available standard therapy.One reviewer found that the Supartz injections in both knees are likely to be more beneficial for treatment of the patients knee pain with osteoarthrosis than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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: Upheld

A 41-year-old female enrollee requested authorization and coverage of an electronic wheelchair for the treatment of peripheral vascular disease.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.