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

The patient is an 11-year-old female with sleep apnea symptoms that date back to age five. She underwent a tonsillectomy and adenoidectomy in August 2001. She continues with obstructive breathing symptoms. A complete sleep study was performed in September 2003. The sleep study documents a respiratory disturbance index (RDI) of 5.7. Nadir oxygen desaturation was 93%. The patients provider prescribed bi-level positive airway pressure (BIPAP) medical therapy since further surgery was not an option at the time. The patient has proceeded with a BIPAP trial, which she has tolerated well (compliance of 87%), and demonstrates significant persistent improvement.The patient also has severe scoliosis and will require spinal fusion surgery in the near future. The patients mother has requested authorization for a BIPAP machine until the patient recovers from her spinal surgery and until further palate surgery can be considered to surgically address her persistent obstructive sleep apnea.The Health Plan has denied authorization for a BIPAP machine on the basis that it is not medically necessary for treatment of the patients medical condition.Childhood obstructive sleep apnea is common (estimated prevalence of 1-3% in preschool children) and can result in significant morbidity. Childhood obstructive sleep apnea syndrome differs significantly from adult obstructive sleep apnea syndrome. Polysomnographic results in the pediatric age group differ from the adult population.On the basis of normative data, an obstructive apnea index of 1 is often chosen as the cutoff for normality. Multiple normative studies have been performed in children and adolescents. The consensus across these studies supports the diagnosis of obstructive sleep apnea in children with a RDI or apnea hypopnea index (AHI) of 1.5 or greater. An RDI of 5 in children and adolescents is considered moderate obstructive sleep apnea. This differs from adult normative data that support the diagnosis of obstructive sleep apnea with a RDI or AHI of 15 or greater.This patient has a RDI of 5.7 after tonsillectomy and adenoidectomy. This indicates moderate obstructive sleep apnea using current normative guidelines in children. As such, use of a BIPAP machine is medically appropriate and indicated. Therefore, I have determined that the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of the medication Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees mixed receptive-expressive language impairment. Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of the request for speech therapy. Although speech therapy is indicated for children with autism, at this time speech therapy is not medically necessary for the patient. The patient does not yet have the behavioral and attention skills needed to benefit from speech therapy. ABA therapy is clinically indicated at this time to address the patients pre-language skills. Based on the clinical documentation submitted for review, the request for speech therapy has not been established as 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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

The parent of a six-year-old male enrollee has requested authorization and coverage for genetic testing for evaluation of the enrollees high-frequency sensorineural hearing loss in the right ear.  Findings:  The physician reviewer found that discussions on the etiology from the American Hearing Research Foundation indicate that 80% of congenital deafness is non-syndromic and due to genetic loci. Of the recessive causes, approximately 50% are due to the gene locus GJB2, which is responsible for the gap protein Connexin 26, which is the most common cause of non-syndromic deafness. Thus, Connexin 26/30 is the most efficient test for non-syndromic congenital deafness in children. In the medical literature, Antonio discussed the value of Connexin 26/30 in evaluation of congenital deafness. The author reported that 50% of pediatric hearing loss is genetic, and of the non-syndromic patients, 50% are autosomal recessive. Further, the author indicated that reduced Connexin 26 generally presents bilaterally, but may present unilaterally. As such, if this patient is Connexin deficient, he will ultimately be deaf in both ears and require a cochlear implant. This knowledge will aid his family in long-term treatment planning and monitoring by the otolaryngologist. Currently, the temporal bone CT and the Connexin 26/30 are both the standard of care for unexplained high frequency unilateral or bilateral deafness. This patient has already been evaluated with a temporal CT therefore the requested diagnostic testing is supported as medically necessary for evaluation of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement for the allergy testing performed. Findings:  The physician reviewer found that In the case of the patient, serum IgE testing for food hypersensitivity can be an appropriate test for evaluating atopic dermatitis according to the standard guidelines for the diagnosis and management of food allergy and the current literature on allergy diagnostic testing . However, IgG4 and IgG4 subclass antibody testing for evaluating food allergy and food allergy related conditions such as atopic dermatitis, do not have clinical relevance, are not validated, and lack sufficient quality control  Thus, the serum IgE food sensitivity testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy while the IgG4 food sensitivity testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number1 is board certified in pediatrics with sub-specialty certification in allergy and immunology and is actively practicing. Physician reviewer number 2 and 3 are board certified in internal medicine with sub-specialty certification in allergy and immunology and are  actively practicing
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three physician reviewers determined that the diagnostic procedure at issue was 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: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested real time heart telemetry monitor services for evaluation of her atrial fibrillation and shortness of breath.  Findings:  Two physician reviewers found that this patient presented with a history of paroxysmal atrial fibrillation and symptoms of palpitations. In this circumstance, non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24-48 hour Holter monitoring is able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Similarly, self-activated non-real time and non-continuous monitoring devices (event recorders) are effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. Current expert consensus guidelines endorsed by several national organizations also consider patient activated event recorders and Holter monitors appropriate for initial evaluation of supraventricular dysrhythmias. There is no documentation to indicate the patient was not able to effectively manage a standard monitoring device or that these devices have been previously obtained to evaluate the patients symptoms. All told, continuous real-time monitoring by telemetry services was not likely to have been more beneficial than standard off-line patient activated or auto-triggered devices in this patients work-up.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested hydrocodone/acetaminophen 10/325 up to twice daily for medical treatment of her chronic low back pain and lumbar disc degeneration.  Findings:  The physician reviewer found that the patient has been on hydrocodone long-term without documentation of improved function or attempted weaning. In addition, the patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  It is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. Consistent with these findings, the requested hydrocodone/acetaminophen 10/325 up to twice daily is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old female who has migraine associated vertigo and a left peripheral vestibulopathy. She has a long-term history of these symptoms. In February 2005, her provider recommended balance retraining with vestibular rehabilitation therapy. The Health Plan has denied coverage for the therapy the patient received.Vestibular therapy is useful for patients who have suffered acute episodes of vestibular problems due to viral disease, stroke, benign positional vertigo or vestibular dysfunction of unknown etiology. However, vestibular therapy is considered ineffective for chronic or recurrent vestibular problems. This patient has chronic vestibular problems. Therefore, the therapy at issue was not medically indicated for this patient. Prophylactic medications such as Topamax or Depakote may be beneficial for this patient. Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested physical therapy services for treatment of her neck and shoulder pain. Findings:  The physician reviewer found that based upon the information provided, the patient had maximized her rehabilitation potential by the date in question. She had already received several months of therapy by that date and her pain is chronic in nature. Furthermore, she had ample time to master a home exercise program by the last authorized date of service. A physical therapy note from the date in question reports the patient was showing good progress with minimal follow-ups. Also, it was noted at that time that the patient had completed her exercise program for treatment of established thoracic and shoulder complaints. Additional treatments beyond the date in question were primarily passive in nature and not likely to improve the patients function.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that according to the most recent guidelines issued by the American Association foe the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Treatment naive patients are recommended to be treated with Harvoni for 12 weeks.  These 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 1 regardless of fibrosis stage.  Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous.  Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Harvoni is medically necessary.  Final Result:  Three reviewers found that the requested medication is medically necessary for treatment of the patients medical condition.  Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty in gastroenterology 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Trio whole exome sequencing (CPT 81415 and 81416 x 2). Thevenon and colleagues report that clinical whole exome sequencing in individuals with undiagnosed and severe forms of intellectual disability and epileptic encephalopathy may have clinical utility in a patient population that frequently undergo multiple clinical evaluations and low-yield laboratory tests often referred to as a diagnostic odyssey. Nolan and Carlson note that in a review of 53 patients, whole exome sequencing improved the presumptive diagnostic rate in the patient cohort from 25% to 48% and that clinical implications included family planning, medication selection, and systemic investigation. The authors concluded that compared to current second tier testing, whole exome sequencing can result in lower long-term charges and more timely diagnosis. Wise and colleagues report that genomic medicine is being used to obtain molecular diagnoses for patients with previously undiagnosed diseases in prenatal, pediatric, and adult clinical settings, while Kuperberg and colleagues concluded that whole exome sequencing is useful in obtaining a high detection rate for previously undiagnosed disorders and that use of this technique could affect diagnosis, treatment, and prognostics for both patients and relatives. Given its likelihood of yielding a prompt, definitive diagnosis that would guide in the treatment of this patient, the requested service is medically indicated. Therefore, Trio whole exome sequencing (CPT 81415 and 81416 x 2) is medically necessary to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; and to correct or ameliorate any physical or behavioral conditions.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 neurology with special certification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested bilateral breast MRI for an evaluation of her breast cancer.  Findings:  Two physician reviewers found that the request was made for bilateral breast MRI for disease surveillance. This request was denied in that it was considered investigational/experimental by the Health Plan. Information and references were provided regarding the use of MRI for screening in patients at high-risk of developing breast cancer as well as the pre-treatment evaluation of local disease. These references do not address the issue of surveillance following the treatment of breast cancer. At the present time, routine radiologic surveillance using any method (mammogram, ultrasound, MRI, etc.) is not recommended following mastectomy. There is insufficient data that routine MRI performed following a mastectomy is helpful for breast cancer surveillance. The patients oncologist noted the patients breasts were without evidence for palpable or visible local recurrence The provider further noted an area of probable area of fat necrosis in the left breast.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested coverage for occupational therapy and speech therapy services for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient has been receiving occupational therapy and speech therapy services for his diagnosis of autism. Both of his therapists have documented improvement in his skills with these therapies. Specifically, the occupational therapist has documented improvement in functional goals including self help skills such as self feeding, dressing and washing hands. These skills do not typically fall under educational services. The patients functional goals are habilitative or rehabilitative and are considered medical in nature. In addition, the speech therapist also documents decreases in the patients expressive and receptive language skills as well as pragmatic skills. While the speech therapy provided by the educational system may be effective for expressive and receptive language, such therapy does not address communication and socialization in the home and community settings. Thus, from a clinical standpoint, the requested speech therapy services are necessary to adequately address all of the patients needs.  Finally, California Assembly Bill (AB) 88 specifically lists autism spectrum disorders as a diagnosis that must be treated in parity with other medical conditions. The submitted documentation confirms the patients diagnosis of autism. Furthermore, as the above-cited literature demonstrates, occupational and speech therapy are well-accepted as standard treatment for patients with autism. Additionally, the records provided document that this patient has functional skills in both activities of daily living and language that are being affected by his diagnosis of autism and progress with therapy has been noted by his providers. Accordingly, the requested occupational therapy and speech therapy services are medically necessary for treatment of this patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a deceased 91-year-old female enrollee has requested ongoing skilled nursing facility services for treatment of the enrollee, status post cerebrovascular accident (CVA). Findings:  The physician reviewer found that the patient had reached her maximum rehabilitation potential as of the date the health plan denied further care. She was near her baseline with ADLs when OT was discontinued and had received several weeks of therapy. The patient could not demonstrate consistent improvement beyond the level that had been achieved by that time.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for hyperbaric oxygen treatment for treatment of her osteomyelitis. Findings:  The physician reviewer found that there is sufficient retrospective data to support hyperbaric oxygen as adjunctive treatment for this patients condition. Hyperbaric oxygen is commonly utilized for treatment of this patients conditions and has a significant likelihood of assisting in substantially improving this patients condition
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested for residential treatment level of care services for treatment of her multiple mental health conditions. Findings:  The physician reviewer found that it is rather uncommon for a patient inactive in treatment to transition directly to the residential setting.  Residential placement is most often utilized as a step-down from acute psychiatric hospitalization or a step up for those who have failed less restrictive interventions such as outpatient therapy or partial hospitalization.  Intensive outpatient care or partial hospitalization would have been appropriate and consistent with accepted medical practice in the United States.  In sum, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 61-year-old male enrollee has requested for emergency services provided at Sonoma Valley Hospital for treatment of his sciatica pain.  Findings:  The physician reviewer found that The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine, severe back and leg pain, and difficulty walking, would reasonably expect the absence of emergency care to jeopardize their health. Therefore, I have determined the services at issue were emergent in nature and medically necessary for treatment of the patients medical condition.