Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency room services provided on 3/14/16. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided on 3/14/16 were necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient is a 52-year-old man who presented with left-sided chest pain. Although his pain had commenced several days prior, it had worsened on the day of presentation. The pain he described was not dull or exertional, as with typical angina, but was associated with sweating. The patient reports that his father died of coronary artery disease at the age of 61, but the patients family history is not noted in the chart. Further, although the patient had no history of hypertension, his blood pressure on arrival was 162/104. The patients EKG showed a non-specific inter-ventricular conduction delay. No ST segment elevations were present, but non-ST segment elevation myocardial infarctions (non-STEMI) may present with non-specific finding on EKG and due to this concern cardiac enzymes were ordered. In addition, the treating provider felt it necessary to order cardiac biomarkers to rule out a cardiac event, and was not content ruling out an acute coronary syndrome based on the patients symptoms and EKG alone. 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: Urgent Care
Decision: Upheld

The parent of a 3-year-old male enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients parent's circumstances would believe the patient was experiencing an emergent medical condition requiring emergency medical services. An emergent  medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This case does not meet the prudent layperson criteria for emergent care. Ear pain in a child for several hours without any other symptoms should not give a prudent layperson reason to suspect immediate threat to life or bodily function/organ. Ear infections are common and well-known among the parents of toddlers, and are mostly caused by viruses for which no treatment is required. A reasonable layperson would know to give the symptom of ear pain time or perhaps contact the on-call provider. Although the ED visit resulted in a prescription for antibiotics these were not immediately necessary. In fact, the literature support a two-day waiting period for all well-appearing children with evidence of an ear infection. If a child does well, antibiotics will typically not be prescribed after the waiting period. As such, the patients symptoms in this case do not meet the prudent layperson standard for emergent medical care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for evaluation by a neurovascular specialist.An increased inter-arm systolic blood pressure difference is usually defined as 10 mm Hg or greater and can be found in up to 24% of healthy persons. Asymmetric blood pressure differences in systolic blood pressure (SBP) of 10 mm Hg or more or 15 mm Hg or more between arms have been associated with peripheral vascular disease and attributed to subclavian stenosis. An increased inter-arm systolic blood pressure difference is associated with an increased risk for incident cardiovascular events. In this case, the patient has had an extensive neurological work-up that did not show evidence of a stroke, aneurysm or blood vessel malformations that would warrant further evaluation by a vascular neurologist or neurovascular specialist. Asymmetric blood pressure can be associated with an increased risk of a cardiovascular event, however, asymmetric blood pressure itself is not an indication for a neurovascular evaluation. Under these circumstances, the requested evaluation by a neurovascular specialist is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

The patient is a 51-year-old male who is requesting authorization for Provigil to treat daytime somnolence. He has an established diagnosis of failed back syndrome with chronic pain. He has taken narcotics and benzodiazepines for pain management. Most recently he has been taking methadone. His daytime somnolence has been attributed to narcotic and benzodiazepine therapy. The Health Plan notes no polysomnography data is available for this patient. The submitted documentation indicates the patient has had 15 office visits for pain management over the last 12 months; five different narcotics have been dispensed, frequently overlapping with different benzodiazepines.Additionally, the patient has taken multiple other medications including Ambien from August 2004 to July 2005 plus overlapping Restoril in March 2005. Physical findings include variable weight from 220-250 pounds over a 12-month period. There is no record of the patients height.The medical records include no reference to the patients sleep habits, including any snoring history. According to the patients provider, Provigil has been clinically effective for treatment of the patients daytime somnolence. The Health Plan has denied coverage for Provigil on the basis the patient does not meet medical necessity criteria for the medication.The medical necessity of Provigil to counter act somnolence due to the effects of other drugs has not been established. Currently, the Food and Drug Administration (FDA) has approved Provigil for the treatment of obstructive sleep apnea, narcolepsy, and shift work disorder. This case involves polypharmacy necessitated by the patients failed back. Review of the patients medications indicate that in addition to the requested Provigil the patient takes sedatives and hypnotics to facilitate his sleep. It appears the patient may be obese but there is no documented evidence of a sleep study and/or polysomnography. The patient may have hypersomnolence secondary to obstructive sleep apnea. Certainly, the degree of polypharmacy involved in this case could facilitate obstructive sleep apnea. As such, a more appropriate therapy may be medication reduction, specifically narcotics and sedatives. If medication reduction is not possible, CPAP and/or BIPAP therapy is a more appropriate alternative than the addition of Provigil to the patients regimen. Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee has requested Imitrex 100mg (#6 tablets/one month supply for treatment of his migraines.  Findings:  The physician reviewer found that triptans are 5 HT1B/1D agonists, with similar mechanisms of action.  All triptans have FDA caution to avoid treating with multiple triptans in a single day.  Such precaution is based on theoretical concerns about excessive serotonergic stimulation, rather than specific evidence of harm.  Most migraine suffers will obtain effective relief with a single tablet, with occasional need to follow up with a second tablet, generally not sooner than two hours after the first.  Early treatment in attacks has been shown to yield better relief than delayed treatment.  Headache experts do at times advise that a patient may switch triptans in a single attack, but do not generally suggest doing so as a matter of routine.  Difficult to manage migraines are often improved with preventive therapy. In this patients case, abortive treatment with Imitrex or Relpax, without mixing doses on the same day, is medically appropriate.  All told, the requested Imitrex 100mg (#6 tablets/one month supply) is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an enrollee has requested authorization and coverage for Norditropin FlexPro. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The patients height is not more than two standard deviations below the mean for age and gender. His insulin-like growth factor 1 (IGF-1) level was normal, and his bone age was normal. He does not have known morphologic abnormalities of his pituitary gland. Although he is relatively short in comparison to his family, he does not meet criteria for growth hormone deficiency. His slight fall-off in growth between 10 and 12 years of age occurred simultaneous with weight fall-off and is not typical of growth hormone deficiency. Therefore, Norditropin FlexPro is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested Zometa for treatment of the enrollees breast cancer.  Findings:  The physician reviewer found that indications for Zometa include treatment of bony metastases and osteoporosis. Two clinical trials demonstrated that zoledronic acid (Zometa) added to endocrine therapy improved disease free survival in premenopausal patients (Gnant, et al; Coleman, et al). The records indicate this provider recommended treatment with Zometa to protect against osteoporosis while the patient is being treated with hormonal ablation therapies. As noted, this patient was on leuprolide for ovarian ablation. For these reasons, the requested Zometa is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for MAKOplasty surgery with preoperative imaging studies associated with the customized right knee replacement. The records provided document that this patient has a history of chronic right knee pain. The patients provider has recommended MAKOplasty surgery given the patients lack of response to conservative measures such as medications, injections, and activity modification. In the peer-reviewed medical literature, Cho and colleagues noted that there robotically assisted surgery can improve the accuracy of prosthetic alignment in total knee arthroplasty (TKA) procedures. However, the authors concluded that despite the enhanced accuracy with robotic assistance, the authors concluded that there were no functional benefits at 10-year follow-up. Similarly, Kim and colleagues found that, At a minimum follow-up of 10 years, we found no differences between robotic-assisted TKA and conventional TKA in terms of functional outcome scores, aseptic loosening, overall survivorship, and complications. Given these findings, the requested MAKOplasty surgery with preoperative imaging studies associated with the customized right knee replacement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested monitored anesthesia care (MAC) administered for a screening colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found the submitted documentation of monitored anesthesia care (MAC) during the patients colonoscopy was not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. In addition, Hausman and Reich state that not all procedures are well suited for the office with sedation. The authors note that unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. A colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per American Society of Anesthesiologists (ASA) guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested continued inpatient acute level of care for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the medical documentation supports a finding of medical necessity for continued inpatient treatment for the patients severe depression. The patient continues to be at significant risk for self harm outside of a 24-hour treatment setting. His history was positive for several past suicide attempts, including attempts after psychiatric hospitalization. His mood remains depressed, he has not responded well to medication; therefore, ECT was initiated. There were and continue to be severe stressors in his recovery environment. Continued inpatient treatment is warranted and consistent with American Psychiatric Association (APA) practice guidelines and Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) guidelines.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested coverage for Viagra 100mg for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication in this patients case. As noted on an authorization request form, the patient has tried Levitra.  The patients provider has reported that Levitra has been ineffective.  However, details regarding the initiation of this medication, its impact, and duration of use were not provided.  The submitted medical records fail to establish an organic cause for the patients erectile dysfunction. In this patients case, the documentation does not demonstrate a workup of hormonal status.  The current medical evidence does not support the requested medication in this clinical situation.
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 neck and upper back. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient developed back and neck pain following a cupping procedure performed by an acupuncturist. Sources show for low back pain, and, as with cervical spine pain, MRI is not routinely recommended unless there are additional signs or symptoms.  The same can be concluded for thoracic back pain. Findings on MRI do not necessarily correlate with symptoms. The only reason to obtain an imaging study is if it will alter the course or type of therapy.  However, even if patients imaging demonstrates degenerative change, the management would include intensive physical therapy, anti-inflammatory medications, and other conservative measures. There is no indication that surgery is being considered. As such, the requested MRI of the neck and upper back is not medically necessary for the evaluation of this patient.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: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET). The health plan has denied this request indicating that IDET is considered investigational for treatment of the enrollees lower back pain.All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. The health plans denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested Rituxan 1000mg intravenous therapy given one week apart for treatment of his medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior effectiveness of the requested therapy.  The clinical documentation indicates that the patient had a disruption in IVIG treatment that caused an increase in symptoms.  However, there is a lack of support for the requested therapy in this clinical setting.  Per the current medical evidence, there is a lack of scientific evidence supporting the long-term safety and efficacy of the requested therapy for the treatment of this patients condition.  As such, the superior efficacy of Rituxan 1000mg intravenous therapy given one week apart has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocortisone valerate cream. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees lichen planus. The submitted documentation does not support the medical necessity of the requested medication. This enrollee has had a trial of hydrocortisone valerate cream with some improvement. The enrollee has not tried and failed the preferred formulary agents, including mometasone cream/ointment/solution, triamcinolone, and cream/ointment/lotion. It is reasonable that the enrollee use the preferred agents for treatment of the enrollees lichen planus, as there are preferred topical steroids of the same potency class as hydrocortisone valerate. Therefore, hydrocortisone valerate cream is not medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested  medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Aubagio 14 mg tablets for treatment of the enrollees relapsing-remitting multiple sclerosis. Findings:  The physician reviewer found that the medical literature supports the requested medication in this clinical setting.  Aubagio is a medication that is approved by the U.S. Food and Drug and Administration for the treatment of relapsing and remitting multiple sclerosis. It is a medication that is widely used by patients who are not able to tolerate or have failed injectable interferon therapies. The studies show that the newer agents like Aubagio are better tolerated and provide a potentially higher efficacy with more likelihood of compliance. In this patients case, the Health Plans preferred medications, Extavia and Rebif, are both injectable interferon medications. The provider noted that this patient is not able to tolerate medications that are injected. For these reasons, Aubagio 14 mg tablets 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 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.