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

A 36-year-old male has requested coverage for a past colonoscopy and prospective coverage for annual colonoscopies due to his personal history of colorectal cancer.  Findings:  The physician reviewer found that for patients with rectal or colon cancer, a colonoscopy is recommended within a few months after resection.  In this patients case, he underwent resection and had a follow-up colonoscopy five months later.  This colonoscopy was negative.  Additionally, it is recommended that patients have a repeat colonoscopy one year after primary resection of colon or rectal cancer to exclude new lesions.  In this patients case, he underwent a follow-up colonoscopy a year later.  This was medically indicated per the current medical evidence for follow-up for this patient with a history of sigmoid colon cancer.  However, since this colonoscopy was negative, the current medical evidence supports follow-up colonoscopy in three years.  If the colonoscopy performed at that time is negative, then the current guidelines support a colonoscopy every five years thereafter.  All told, the colonoscopy obtained a year after the original follow-up colonoscopy was medically indicated for the evaluation of this patient.  Per the submitted documentation, the requested annual colonoscopies are not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for inpatient psychiatric services. Applying CALOCUS, this patient met the criteria for inpatient psychiatric services. The patient was at extreme risk of harm (score 5) due to consistent self-harm and physical aggression toward herself. The provider noted that the patient demonstrated a lack of insight and judgment resulting in significant bruising of her body. During treatment, the patient showed severe functional impairment (score 5) given her serious deterioration of her interpersonal interactions with family and with other peers on the unit. The patient was unable to function in an academic setting and was aggressive toward herself despite being in treatment. For comorbidity, the patients psychiatric symptoms impaired her functioning and ability to participate in treatment (score 4). The patients recovery environment was minimally stressful (score 1) as the patient performed role expectations consistent with her age and developmental level. In addition, her recovery environment provided limited support (score 3) due to inadequate community resources available to address the patients behavior and condition. The patient was inaccessible in treatment (score 5) as she continued to engage in self-harm behavior when exposed to stress. Although the patient did not make substantial progress, she was constructive in treatment (score 2), due to passive cooperation in treatment. This gives the patient a composite score of 25, which is consistent with Level 5, medically monitored residence based services. However, due to the severity of the patients condition and the lack of medically monitored residence services available, placement in a Level 6, medically managed residence based program, such as inpatient psychiatric level of care, was appropriate until she could be placed in a Level 5 facility. All told, the records demonstrate that the inpatient psychiatric services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty certification in child and adolescent psychiatry 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 reimbursement for the Njx platelet rich plasma (CPT code 0232T). After careful review of the enclosed information and the pertinent literature and guidelines concerning platelet rich plasma injections, the Njx platelet rich plasma (CPT code 0232T) provided on 5/25/18 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Most of the studies on platelet rich plasma injections have been performed for the treatment of lateral epicondylitis. Platelet rich plasma injections may improve healing of tendons, but the treatment is not considered standard of care. Given these findings, the Njx platelet rich plasma (CPT code 0232T) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Njx platelet rich plasma (CPT code 0232T) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Njx platelet rich plasma (CPT code 0232T) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for treatment of her medical condition. Findings: Two physician reviewers found that the use of Botox injections in clinical medicine has significantly improved management of many movement disorders, spasticity, and syndromes of autonomic over activity. In a pilot study from Australia of women with chronic pelvic pain and demonstrable spasm in the pelvic floor muscles, a reduction in pressure was found when botulinum toxin type A was injected, and a diminution of pain symptoms was noted. A follow up study of small patient numbers was performed to evaluate the treatments effect on pelvic floor pressure, pain response, and impact on quality of life. In this randomized controlled trial, 60 women with chronic pelvic pain and high-tone pelvic floor dysfunction were randomized to receive 80 units of Botox type A (BTA) injected into their pelvic floor muscles (n = 30) versus saline (n = 30) and followed for 26 weeks. The BTA group showed a significant decrease in both nonmenstrual pelvic pain and dyspareunia compared with baseline. In the placebo group, only dyspareunia was reduced. There was no difference when the pain scores of the two groups were compared. Resting vaginal pressures were significantly lower in the BTA group for up to 16 weeks after injection. Reported side effects included temporary urinary and anal incontinence. A significant placebo effect was noted. The primary and secondary outcomes were not well defined. There were significant intragroup differences in pain, but it can be concluded that there is no significant treatment effect when compared to placebo. Therefore, there is a lack of definitive evidence in the peer-reviewed literature that Botox injections are significantly effective for the patients medical condition. At this time, more trials are needed to confirm its effectiveness in the treatment of chronic pelvic pain. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two 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 obstetrics and gynecology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter valve repair. Based on the records provided, this patient presents with symptomatic severe mitral regurgitation and high surgical risk due to comorbid conditions and inability to safely discontinue Plavix medication in the setting of a recent left main coronary stent placement. In this circumstance, percutaneous valve repair has shown to be a safe and effective alternative compared to open surgical repair for reducing mitral regurgitation in a relative large randomized trial. There is sufficient clinical data to support percutaneous repair with MitraClip for patients with prohibitively high risk for open surgical repair and suitable valve morphology. For these reasons, percutaneous mitral valve repair using MitraClip is appropriate in this patients circumstance. Accordingly, the requested transcatheter valve repair is likely to be more beneficial for the patients condition than any available standard therapy.  One reviewer found that the requested transcatheter valve repair is not likely to be more beneficial for the patients condition than any available standard therapy.  Final Result: Two of the three reviewers determined that the requested service is 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Overturned

A 26-year-old male enrollee has requested for emergency services.  Findings:  The physician reviewer found that at the time of presentation at the hospital, the patient reported that the abdominal pain had dissipated. There is no mention of abdominal pain in the chart, and his abdominal examination was documented as benign. Blood work was unremarkable.The patient describes having suffered from extreme abdominal pain as well as rectal bleeding. This constitutes acute symptoms of sufficient severity that would lead a prudent layperson to believe failure to obtain immediate medical attention could result in serious jeopardy to health, bodily functions, and/or life.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested autonomic nervous system function testing for evaluation of her medical condition.  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient had autonomic symptoms that had led to four prior hospitalizations.  In cases such as these, autonomic testing, including the tilt table test, is reasonable and standard of care to further evaluate the etiology of the described symptoms.  In this case, this testing led to a diagnosis while excluding other potential etiologies of the patients symptoms.  All told, autonomic nervous system function testing was likely to have been of greater benefit than other available modalities.  Final Result: Two 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:  All three reviewers are board certified in neurology 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 patient has requested authorization and coverage for Prevention Genetics Autism Spectrum Disorders and Intellectual Disability Comprehensive Panel gene testing (ASD-ID Panel Trio - test code 11865). In a systematic retrospective chart review of 48 patients with intellectual disability and global developmental delay who underwent an intellectual disability gene panel, Authors found the diagnostic yield was 21% overall, and 38% with more recent trio-based panels. They concluded that intellectual disability gene panels have a high yield and are a valuable diagnostic tool. Researchers noted that neurogenetics investigations and diagnostic yield in patients with autism spectrum disorder (ASD) have significantly improved over the last few years. The authors reported that high-throughput resequencing of reported intellectual disability/ASD genes to the screening procedure had a major impact on diagnostic yield in the 141 patients examined who had tested negative for fragile X syndrome and pathogenic copy number variants (CNVs). In this case, the testing performed to date, including the SNP test and gene panels for the RYR1 and BIN1 gene mutations, did not reveal a reason for the patients autism. A definitive genetic cause for the patients autism may be established by a comprehensive gene panel test, which may have additional implications for his health monitoring and interventions. Given that at present the cause for the patients autism has not been established, a comprehensive gene panel test is medically indicated. Therefore, Prevention Genetics Autism Spectrum Disorders and Intellectual Disability Comprehensive Panel gene testing (ASD-ID Panel Trio - test code 11865) is medically necessary to prevent disease, disability, and other health conditions or their progression. Final Result: The reviewer determined that the requested service is medically necessary for the treatment 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: Urgent Care
Decision: Upheld

A 52-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient had been experiencing back pain for two weeks in duration. She states that she had new onset of numbness in her legs, which along with her pain caused her to seek emergency services. However, the emergency department records do not indicate the numbness was a new symptom. The records note numb pain with duration noted as weeks. In addition, no acute neurological symptoms such as weakness, paralysis, or bowel or bladder dysfunction are documented in the records provided. Further, the patients pain level was noted as 6 and 7 in the submitted records, which indicates moderate but not severe pain. Thus, this patients symptoms did not meet the prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize her health or cause serious impairment or dysfunction.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for speech therapy, three hours (180 minutes) per month. The enrollee has autism spectrum disorder, attention deficit hyperactivity disorder, and developmental expressive language disorder. He received services from a speech therapy facility. He has received applied behavioral analysis services since age three. His mother states the speech therapy facility was not supportive due to her sons attention deficit hyperactivity disorder. His mother reports that they tried medication for his attention deficit hyperactivity disorder, but it was not beneficial, resulted in side effects, and they discontinued the medication. The enrollees mother is requesting three hours (180 minutes) per month of speech therapy with a new vendor. The enrollees applied behavioral analysis provider noted his deficiency in joint attention skills and his disruptive behaviors during speech therapy sessions. The applied behavioral analysis provider recommended the enrollee continue working on improving his behavioral and attentional skills through applied behavioral analysis therapy. The enrollees treating speech language pathologist noted the enrollees progress had plateaued. The enrollees mother feels that if the enrollee stays at the current speech therapy facility, he will not be supported. The enrollees mother states the current speech therapy facility designed a plan and discharge without consultation or input from her or any other providers. She is requesting coverage for a change in vendor. This enrollee was having difficulty with attention.  The enrollee had constant extraneous movements of the arms and legs.  The enrollee engaged in attention-seeking behaviors intermittently throughout the session, which impeded therapy progress.  The behaviors were escalating and unpredictable.  Documentation noted minimal improvement of progress-to-goal was seen throughout the authorization. The enrollee met zero of four goals during the therapy period. Literature notes most children with autism spectrum disorder will benefit from therapies designed to improve their ability to communicate and engage in social interactions. However, while this enrollee had been receiving speech therapy, the speech language pathologist noted the enrollees inattention to tasks continued to negatively impact his progress towards his goals. It did not appear the enrollee had the appropriate behavioral skills to allow for improvement in speech through speech therapy services. Therefore, the therapy would not be effective.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 pediatric 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested electrical bone growth stimulator for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that there is a lack of support for the device at issue in this patients case.  The current literature supports electrical stimulation for healing of long bone nonunion or fresh fractures with significant risk factors.  However, similar literature does not exist for healing of sesamoid bone stress fractures in the foot.  Furthermore, the imaging study does not support the diagnosis of a stress fracture of the sesamoid bone.  The MRI report indicates presence of a bipartite sesamoid.  In light of the foregoing, the request for a bone growth stimulator is not supported by the literature.  As such, the electrical bone growth stimulator was not likely to have been of greater benefit than other treatment options.Final Result: Three reviewers determined that the device at issue was 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with heterogeneously or extremely dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying architectural distortion/mass, resulting in a decrease in biopsies, increase detection of small cancers and decrease in callbacks. Thus, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: 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: All three 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.