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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for MRI scans of the bones of the eye, face, and neck, before and after contrast. The enrollee has cardiovascular symptoms, which are being attributed to an infectious disease process. She has undergone an echocardiogram, stress test, and carotid Doppler. A computed tomography scan of the head and a magnetic resonance imaging scan of the brain were normal. Stool testing was positive for Blastocytosis hominis. The enrollee is requesting coverage for a magnetic resonance imaging scan of the orbits, face, and neck. The enrollee reports she has an irregular heart rhythm and persistent chest pain. She asserts the magnetic resonance imaging scans are required to establish a proper diagnosis and make it possible for her to receive disease-specific therapy. Generally, the decision to pursue diagnostic imaging tests is based on clinical suspicion; including physical findings, presenting symptoms, laboratory results, and the persons history of illness. For this enrollee, the request for the magnetic resonance imaging scans seems arbitrary and not evidence-based. Records show the enrollees stool tested positive for Blastocystis hominis, a gastrointestinal parasite infection. Currently, controversy exists as to whether this parasite is truly pathogenic or a normal intestinal organism. There has never been a reported case of a disseminated Blastocystis hominis infection involving the orbits, face, or neck. Based on the above findings, there was no documented medical necessity for the requested magnetic resonance imaging scans.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in infectious disease 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: Overturned

A 71-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her depression.  Findings:  The physician reviewer found that the transcranial magnetic stimulation (TMS) was medically necessary for treatment of the patients medical condition. TMS is endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this particular case, the patient was reportedly experiencing an acute major depressive episode that caused significant functional impairment despite prescription of an appropriately dosed selective serotonin reuptake inhibitor. In addition, a serotonin-norepinephrine reuptake inhibitor was not efficacious. She was previously prescribed medications from the tricyclic and monoamine oxidase inhibitor classes of antidepressants. She was treated in the outpatient and intensive outpatient levels of care and electroconvulsive therapy resulted in problematic side effects. Given this documentation in the medical records reviewed and endorsement from the APA and the expanding peer-reviewed literature base, TMS was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and is more effective than corticosteroid injections.  In this case, the patient has been diagnosed with osteoarthritis of both knees.  She had been treated with corticosteroid injections, bracing, physical therapy, exercise, medications, and activity modification, without sustained relief.  She has undergone prior series of Synvisc One injections for five years, with reported significant sustained pain relief allowing improved mobility. Therefore, the requested Synvisc One injections are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy once daily for treatment of enrollee's hepatitis B.  Findings: The physician reviewer has found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the formulary alternative, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease.  Therefore, the requested Vemlidy 25 mg tablets, once daily is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Overturned

A 55-year-old female enrollee has requested for Thalomid for treatment of her condition.   Findings:  Two physician reviewers found that there is no standard therapy for metastatic islet cell cancer. A phase II study of the combination of thalidomide and temzolomide revealed a very promising degree of clinical activity. For this disease with no standard treatment options, this combination is promising.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested Lipitor 10mg twice daily for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that there is no documentation provided necessitating twice daily Lipitor at the requested dosage. Statins are best prescribed to be taken once a day in the evening. This is the time of greatest cholesterol synthesis. There is no evidence in the medical literature supporting twice daily statin dosing.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Forteo 600 mg/2.4 mL 20 mcg subcutaneous by self-injection, with 11 refills. Findings:  The physician reviewer found that (FDA) approves the use of Forteo for the treatment of postmenopausal women with osteoporosis at a high risk for fracture. Babu and colleagues report that teriparatide (brand name Forteo) has been shown to increase bone mass and prevent fractures in osteoporotic bone. In this case, the patient has sustained atraumatic fractures and is at an increased risk of future fractures. In this clinical setting, the requested medication is medically indicated. Therefore, Forteo 600 mg/2.4 mL 20 mcg subcutaneous by self-injection, with 11 refills, is medically necessary 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested residential treatment services for treatment of the enrollees depression with suicidal ideation. Findings:  The physician reviewer found that the records provided for review do not include documentation supporting the medical necessity of RTC level of care services for this patient from the date indicated and forward. The patient is not described as suicidal or as a risk of harm to others. Overall, the patient has many somatic complaints, which are viewed as being potentially manipulative in nature. However, there is a lack of evidence that the patient requires the intensity and supervision of services provided at the RTC level of care. All told, the RTC services provided from the date indicated and forward are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) device (CPT code E0601). The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees obstructive sleep apnea. The submitted documentation supports the medical necessity of the requested device. Based on a home sleep study, this patient has a diagnosis of mild obstructive sleep apnea with a AHI of 9.4. Home sleep studies are known to underestimate the severity of obstructuve sleep apnea. They overestimate sleep time which is the denominator, therefore decreasing the quotient to a smaller number. The American Academy of Sleep Medicine states that CPAP is beneficial for the  treatment of mild obstructive sleep apnea.  Therefore, the requested CPAP device (CPT code E0601) is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certificaiton in sleep 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bone density testing. Osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of these, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis. Osteopenia, a condition in which bone mineral density is lower than normal, is considered by many physicians to be a precursor to osteoporosis. Given this patients postmenopausal status and her comorbidities, the bone density testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the bone density testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the bone density testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.   Findings:  The physician reviewer found that the patient presented to the emergency department with reports of abdominal pain located in the lower abdomen that began suddenly two days prior and had become persistent. Her symptoms commenced after eating pizza. She reported nausea, vomiting and low back pain. The patients past medical history included diabetes and hypercholesterolemia. Her vital signs showed a blood pressure of 122/69, temperature of 98.3 F and pulse of 72. Mild abdominal tenderness was present in all four quadrants with a positive Murphys sign. Laboratory data revealed ketonuria with a glucose of 144, but was unremarkable. An abdominal ultrasound was negative for gallstones or cholecystitis. A computed tomography (CT) scan of the abdomen and pelvis showed signs of gastritis. The patient was medicated with intravenous fluids and antiemetics. She was assessed with abdominal pain and discharged in stable condition.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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with abdominal pain and vomiting. Her symptoms had commenced 36 hours prior, had persisted, and worsened. Due to the patients history of diabetes, she was concerned that she might become dehydrated. Diabetic patients with persistent vomiting are also at risk for diabetic ketoacidosis. Abdominal tenderness with a positive Murphys sign was present, which is a potential indicator of acute cholecystitis. Such patients may not be safely discharged until dehydration with acidosis as well as an acute surgical abdomen have been ruled out. The care provided in the emergency department was for emergency services. As such, the patient received emergency medical services.  Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer 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

The parent of a nine-year-old male enrollee has requested the medication Invega for the treatment of the enrollees Tourette Syndrome and Attention Deficit Hyperactivity Disorder (ADHD). Findings:  The physician reviewer found that the safety and efficacy of Invega in children and adolescents has not been studied nor established. Invega is not the standard of care for adult patients with either Attention Deficit Hyperactivity Disorder or Tourette Syndrome.  The off label use of Invega for Attention Deficit Hyperactivity Disorder and/or Tourette Syndrome is at present considered investigational. The use of Invega by a nine-year-old patient is also considered investigational and not the standard of care for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the inpatient hospital stay for treatment of the enrollees chest pain. Findings:  The physician reviewer found that the evaluation of chest pain has been the subject of much study. Most centers now follow the use of the chest pain center as a method for evaluating patients in the outpatient or observation status and inpatient admission is reserved for true acute coronary syndrome or myocardial infarction in patients with positive troponin enzymes. In addition, noted that many emergency department presentations for chest pain with low risk features may be deferred for cardiac testing and safely followed up on an outpatient basis without cardiac testing. This patient presented with chest pain and negative troponin results. Thus, the patient could have been managed as an outpatient or with observation through a chest pain unit or similar procedure without inpatient admission. All told, the inpatient hospital stay services provided were not medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: The patient has requested authorization and coverage for implantation of a hypoglossal nerve stimulator. Findings: Two physician reviewers found that CPAP is the most common type of therapy for patients with severe OSA. Hypoglossal nerve stimulation therapy has been proven by the U.S. Food and Drug Administration (FDA) to be an effective modality of treatment of OSA in patients with tongue-based obstruction. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Candidates for hypoglossal nerve stimulation includes patients who have failed, or are not candidates for CPAP or a dental device. Other criteria include an AHI between 15 and 65 on a recent sleep study, no more than 25 percent central apneas (including mixed), and a body mass index (BMI) of 35 or less. This patient continues to manifest obesity with a BMI over the criteria. Specific to this patients case, there are standard interventions that are likely to be more effective than the requested procedure. In addition, alternative therapy was not documented in the current clinical records. All told, the requested implantation of a hypoglossal nerve stimulator is not likely to be more beneficial than standard available therapies for treatment of this patients medical condition. One reviewer concluded that the requested implantation of a hypoglossal nerve stimulator 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 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 otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned

A 64-year-old male has requested glossectomy using heat (coblation or radiofrequency) for treatment of his sleep apnea.  Findings:  Two physician reviewers found that the patient has been diagnosed with severe obstructive sleep apnea via polysomnography.  The patient was noted to have nasal obstruction with septal deviation and turbinate hyperplasia.  The submitted documentation noted an enlarged tongue base.  The patient has requested coverage for glossectomy using heat (coblation or radiofrequency).  The Health Plan has denied this request and reported that the requested procedure is investigational for the treatment of this patient.  This denial is the subject of this appeal.  The current medical evidence supports the superior efficacy of the requested procedure in this patients case.  Radiofrequency ablation for tongue base reduction results in improvement of objective measurement of obstructive sleep apnea parameters.  Tongue base reduction by other surgical methods carries high morbidity and may necessitate tracheostomy, while radiofrequency tongue base reduction carries minimal morbidity.  The medical literature has shown favorable outcome and low morbidity of this procedure.  All told, glossectomy using heat (coblation or radiofrequency) is likely to be superior over other available treatment options in this patients case.