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

The parent of a 16-year-old female enrollee has requested acute inpatient admission care for treatment of the enrollees diabetes and depression with borderline personality disorder. Findings:  The physician reviewer found that the combination of poorly controlled type 1 diabetes and multiple psychiatric disorders, suggests this patient was a high mortality risk (Grey and colleagues). Therefore, the hospitalization during the entire period in question was medically necessary. During the time period at issue, the patient received continued blood glucose monitoring and adjustment of insulin doses. Since her admission blood glucose level was 500 mg/dL while on a regimen of basal/bolus insulin with long-acting Lantus, several days were required for stabilization of blood sugar levels in order to ascertain the full effects of the Lantus. The treatment provided was appropriate particularly in light of the fact that the patient is noted to have threatened suicide by overeating and skipping meals, thus causing erratic blood sugar levels. With an HbA1c of 9.2%, it is highly likely that the patients adherence to the prescribed insulin doses was suboptimal prior to admission, and continued observation was therefore indicated to ensure that prescribed doses were appropriate and would not result in severe hypoglycemia. In addition, a providers note on the second day of treatment states that the patients swelling had worsened after Benadryl was discontinued. Overall, this patients significant risk of morbidity and mortality with co-existing depression and diabetes, with superimposed acute hyperglycemia and allergic reaction, warranted the full duration of hospitalization.
Appeal type: Medical Necessity
Decision: Overturned

 A sixty-four year-old female with a complaint of osteoarthritis in her thumbs and wrists is requesting authorization for acupuncture therapy.Reviewers Findings:  The reviewing physician found that the patient had exhausted the more standard treatment modalities for the arthritis and the provider has referred the patient for acupuncture therapy. Arthritis is one of the conditions commonly treated by acupuncture.  The reviewing physician found the as the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the thoracic spine and discography for evaluation of the enrollees neck and back pain with radiculopathy.Findings:  The physician reviewer found that the records do not include any evidence of concerning findings to provide an indication of immediate MRI scan of the thoracic spine. Moreover, there is no documentation of a plain x-ray report of a thoracic spine series or evidence of fracture on prior imaging. Neurological examination shows no absent reflexes or other red flags. The patient has been referred for a 12 week program of aqua therapy and stretching, which has not reportedly begun. Thus, the requested MRI of the thoracic spine is not medically necessary. In addition, discography is reserved as a problem solving tool in rare instances when no explanation can be found for a patients symptoms despite standard imaging such as MRI and its use as a diagnostic test in this clinical setting is not considered to be within the standard of care. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

A 64-year-old female enrollee has requested follow-up services with her current podiatrist for the treatment of her fractured toe. Findings:  The physician reviewer found that this patient has several podiatric conditions which appear to be active from a review of the submitted medical records. Specifically, she has a recent fracture of her right 5th toe, a Morton's neuroma of her right foot, and bilateral heel spurs with secondary pain. The patient continues to be symptomatic. Thus, continued follow-up with the patients current podiatrist is medically appropriate and indicated given the patients combined foot impairments.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 18-year-old female with cerebral palsy with spastic quadriplegia.  She is dependent for all activities of daily living. She takes nothing by mouth and uses a gastrostomy tube for all nutrition. She receives bolus feeds and is tolerating all feedings.  Her weight is stable.  She has a history of constipation, but it is manageable with medications. The patient has had no recent medical issues requiring admission to the hospital. She receives oral medications for spasticity and GI issues, but no IV medications. At issue is whether continued in-home skilled nursing care is medically necessary.Upon review of the submitted clinical records and the needs associated with this patients medical care there are no services that cannot be provided by a trained attendant. There is no clinical indication for skilled nursing or skilled rehabilitation services in this particular setting. The patients needs are custodial in nature and therefore continued in-home skilled nursing services are not warranted. Accordingly, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested a self-rotating bed (Pro-Bed) for treatment of his amyotrophic lateral sclerosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The patient is reported to have amyotrophic lateral sclerosis, a disorder which causes loss of physical functions such as swallowing, intelligibility of speech, ventilatory function and limb control.  Disease-modifying therapy does not appreciably mitigate the functional deterioration associated with this disease.  Treatment generally revolves around optimal supportive and palliative care, including non-invasive ventilation support, power wheelchairs for independent mobility, and supportive bedding and other strategies for the prevention and management of pressure sores.  In this patients case, there is no documented prescription, letter of medical necessity or rationale for its use written by a health care provider.  It is also unclear from the records whether the requested device would be safe for the patient given his suboptimal secretion management and dysphagia.  The head of bed elevation for the requested bed is limited to 30 degrees while in the fully rotated position, which may potentially increase his risk for respiratory complications, including aspiration.  All told, the requested self-rotating bed (Pro-Bed) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested  for minimally invasive interbody fusion at L5-S1 using the Dynesys Spinal System for treatment of his low back pain. Findings:  Three physician reviewers found that the Dynesys system is not currently accepted as standard of care for spinal surgery.  This is a non-fusion, pedicle screw stabilization system using flexible materials intended to stabilize the affected lumbar region while preserving the natural anatomy of the spine. The system was developed in an attempt to overcome the disadvantages of rigid instrumentation and fusion. This system remains investigational and requires additional long-term studies to conclusively establish efficacy greater than standard methods of treatment. Additionally, there is no documentation that this individual underwent discography to determine if this was, if fact, the painful level.  Prior to undertaking any type of fusion surgery, all pain generators should be identified.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 54-year-old female enrollee has requested authorization and coverage for acupuncture two times per week for treatment of the enrollees low back pain and lumbago with sciatica.  Findings:  The physician reviewer found that the records provided for review document that this patient presents with chronic pain that has been unresponsive to prior medication and injection therapies. Three acupuncture sessions were provided with approximately two to three weeks between visits, with some symptomatic relief. The current peer-reviewed medical literature reveals that acupuncture is more effective than placebo. As this patient continues to complain of chronic lower back pain, six consecutive weekly acupuncture sessions are supported as medically necessary. Further care, beyond the trial, will be based on the patients symptoms, functional benefits obtained with these treatment sessions and the residual functional-sensory-motor deficits that need to be addressed. Accordingly, six acupuncture sessions are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in oriental 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance neurography for evaluation of the enrollee, who has been diagnosed with left lumbosacral plexopathy. Findings:  Two physician reviewers found that the medical literature has not demonstrated the superior efficacy of the requested services.  The studies did not involve large numbers and were retrospective.  Additionally, the study was of the ulnar nerve.  There is a lack of large, randomized studies relating to the sciatic nerve or the lumbosacral plexus that have shown the efficacy and utility of this radiographic procedure.  As such, the requested magnetic resonance neurography is not likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 physician reviewers are board certified in neurological surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested laser spine surgery for medical treatment of her low back pain.,  Findings:  The physician reviewer found that the medical evidence supports a trial of conservative care emphasizing patient education, modality physical therapies and pain clinic care.  The lack of precise localization as to index level will limit the efficacy of any surgical intervention.  All told, the requested laser spine surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue in this case is whether rigid functional orthotics (shoe inserts) are medically necessary for treatment of the patients medical condition. Findings:  The physician reviewer found that he has a recent history of a left foot stress injury to the second metatarsal. The provider noted that compensation due to prior surgeries has allowed for increased lateral left forefoot and midfoot pressure and pain. The patient is using green over-the-counter (OTC) redithotic orthotics, which are not sufficient to support him. The physical examination revealed mild edema and pain with palpation of the left third interspace and plantar left fourth metatarsal head.The medical records and current medical literature support the use of custom orthotics in this clinical setting. He was diagnosed with left fourth metatarsalgia and left third interspace neuroma with pain. The patient is also noted to have scar tissue from prior surgeries and has failed conservative treatment with OTC orthotics. The providers notes that the patient needs more support to the left foot to reduce overpronation, which will defer friction and pressure from the painful areas. The requested equipment is within the current standard of care, which advises that custom functional orthotics may be utilized to offload pressure from the forefoot and midfoot.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 podiatry. 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 patient is a 61-year-old male with hepatitis C.  He was treated with Pegasys and ribavirin for one year and has since relapsed. The patients provider has requested authorization for retreatment with Infergen and ribavirin. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.Infergen has been approved by the FDA and is specifically indicated for the treatment of patients who have not responded to pegylated interferon therapy. This patient was compliant with the prescribed pegylated formulation treatment and has now relapsed as demonstrated by a viral load of 4,649,000 IU/ml. At this point, it is reasonable to proceed with Infergen therapy.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The addition of breast tomosynthesis to screening films has gained wide support among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  In this patients case, the addition of digital breast tomosynthesis was likely to have been more beneficial than digital mammography without tomosynthesis.  All told, the medical records establish the superior efficacy of breast tomosynthesis.  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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested magnetic resonance guidance and MRI scan of the pelvis for the evaluation of her piriformis syndrome. Findings:  Two physician reviewers found that although the magnetic resonance guidance and MRI of the pelvis were not the standard of care for this patient, they were more likely to be of benefit to this particular patient than any other additional imaging modality and intervention. This patient has already undergone spinal surgery with incomplete resolution of symptoms, a postoperative MRI scan including contrast injection and a CT myelogram. Since conventional surgery, imaging studies and routine evaluation have failed to elucidate the etiology of her persistent symptoms, a new technique such as MRI guided neurography and intervention may offer benefit to the patient.  In addition, it would be prudent to exclude other soft tissue diseases such as nerve sheath tumor, myositis, or pelvic side wall masses as the etiology of symptoms. Routine exams of the lumbar spine do not cover the anatomical areas necessary for evaluation outside of the lumbar spine, and there was no real alternative evaluation or treatment offered by any other provider.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested occupational and speech therapy services for treatment of his autism.  Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that ST and OT are medically necessary interventions for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and ST and OT can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood.
Appeal type: Urgent Care
Decision: Upheld

The parent of a four-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe their child 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 experienced the onset of an earache and medication was administered at home. Upon presentation to the emergency department, the patient appeared to be in no distress, as documented by both the physician and triage nurse. Her mother denied that the patient was experiencing shortness of breath or vomiting. The same patient had been treated for an ear infection within the past three months. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. A prudent layperson in the parents circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize the patients health, particularly in light of the patients prior history of ear infection.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested a screening colonoscopy for evaluation of herself, who has a family history of colon cancer. Findings:  The physician reviewer found the submitted documentation demonstrates the medical necessity of the requested services in this clinical setting.  This patient has a family history of colon cancer.  Per the medical records, she presented to her provider and reported rectal bleeding. The current medical evidence supports a repeat screening colonoscopy in this patients case.  The patients current symptoms necessitate a colonoscopy for further evaluation.  All told, the requested repeat screening colonoscopy is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depression, recurrent, severe, without psychotic features.  Findings:  Two physician reviewers found that the patient is a 49-year-old female with major depressive disorder.  Per the submitted documentation, her treatment history has included mood stabilizers, second-generation antipsychotics, psychotherapy, light therapy and electroconvulsive therapy. The provider noted that patient suffered memory loss and disorientation following electroconvulsive therapy.  The medical records indicate that the patient has been under psychiatric care since she was a minor.  She has requested authorization and coverage for transcranial magnetic stimulation. The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient. The patients treatment-resistant major depressive disorder is well-documented.  There is support in the literature regarding the efficacy and safety of transcranial magnetic stimulation for treatment-resistant depression.  The study by George and colleagues confirmed the benefit and safety of transcranial magnetic stimulation for adult patients with major depression. Janicak and colleagues indicated that transcranial magnetic stimulation has demonstrated efficacy in the treatment of major depressive disorder. Demitrack and Thase noted that transcranial magnetic stimulation is safer and better tolerated than many other pharmacotherapeutic options or electroconvulsive therapy.  All told, the requested transcranial magnetic stimulation is likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested for a consultation regarding a liver mass and possible liver transplant for treatment of his liver mass.  Findings:  The physician reviewer found that Yao and colleagues showed that there may be room to expand these criteria without affecting survival outcome (Hepatology, 2001 Jun;33(6):1394-403). In another study, the authors found that patients with HCC meeting the following criteria: solitary tumor less than or equal to 6.5 cm, or 3 or less nodules with the largest lesion less than or equal to 4.5 cm and a total tumor burden less than or equal to 8 cm, had survival rates of 90% and 75.2% at one- and five-years respectively, after orthotopic liver transplantation versus a 50% one-year survival rate for patients with tumors exceeding these limits (Hepatology, 2003;33(6):1394-1403).The evidence demonstrates that this patient has a liver tumor which is 8.6 cm in largest diameter, which even exceeds the expanded criteria, and therefore, he is not deemed an appropriate candidate for liver transplant due to high risk of recurrence of the tumor post-transplant.