Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested Rituxan (rituximab) infusions for treatment of her neuromyelitis optica. Findings:  The physician reviewer found that neuromyelitis optica (NMO) is an inflammatory demyelinating disorder of the central nervous system that almost exclusively affects the optic nerves and spinal cord. Because pathological and serological studies suggest that NMO appears to be, at least in part, a B-cell mediated disease Rituxan has been considered a potentially effective treatment. However, studies to date have been small and not controlled. Well-designed clinical trials are needed to assess treatment effects in this rare disorder. The safety and tolerability of Rituxan in NMO is currently the subject of a clinical trial. Given the unproven efficacy of Rituxan in this setting, its use is not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera for treatment of the enrollees relapsing remitting multiple sclerosis (RRMS). Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication.  There is a lack of evidence demonstrating that Tecfidera is more effective than the Health Plans available formulary agents. Two of the three Health Plan formulary agents are injectable, and the other is an intravenous therapy. In this case, the patient presents with relapsing remitting MS with active disease as evidenced by increased activity on MRI. Thus, changing to another MS disease-modifying agent is indicated. However, there is a lack of evidence in the peer-reviewed literature supporting the superiority of Tecfidera compared to the Health Plans available disease-modifying agents. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Urgent Care
Decision: Overturned

A 23-year-old female enrollee has requested services on an emergent basis.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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. Review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. This patient had pain in her knee that could not be explained by any recent injury. The patients pain had persisted for six hours prior to her presenting to the emergency room to have it evaluated. Moreover, the patients pain rated as 7 out of 10, and this level qualifies as severe pain. A prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. Therefore, the patients symptoms on the said date met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested Mirena IUD for the treatment of her menorrhagia.  Findings:  Three physician reviewers found that Mirena IUD has been demonstrated to be effective in the treatment of menorrhagia. It can also be useful for dysmenorrhea. This patient cannot tolerate birth control pills. The requested IUD is likely to be more successful for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the hip for an evaluation of her hip problem. Findings:  The physician reviewer found that in most cases the evaluation of a patient with hip pain with history, physical examination, and plain radiographs, leads to a diagnosis (the American Academy of Orthopedic Surgeons (AAOS)). Erb suggested that when this assessment does not provide a diagnosis, an MRI may provide additional information of value, especially in detecting marrow-based abnormalities. However, as noted by Newberg and Newman, conventional plain radiography remains the key-role in the assessment of symptomatic hips. In this case, there is no documentation of any plain film study of the hip, noting only a reported finding six years earlier. There is a lack of documentation of any abnormal findings on examination of the hips. Since there is a lack of documentation of indications for an MRI of the hip, the Health Plans denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that the American College of Radiology (ACR) urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging only. Therefore, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for allergy injections. Based on the available documentation, the requested immunotherapy does not meet the current guidelines for medical necessity. In this case, review of the chart showed insufficient documentation in several areas. Specifically, clinical information is not documented to demonstrate sufficient physiologic or functional limitations or level of incapacity of the patients condition, therapies tried and failed, list of therapeutic plan and goals to be achieved, and rationale for additional injection doses of immunotherapy. Per the Allergy Practice Parameters on dosing, immunotherapy level of efficacy can be determined by measuring objective and subjective parameters. In addition, the American College of Allergy, Asthma and Immunology has taken the position that any limits on coverage should not be less than 150 doses during the build-up year and not less than 90 doses thereafter for maintenance. However, in the case of this patient, medical chart documentation did not provide a rationale for additional injection doses of immunotherapy above Health Plans dose limitation policy. Thus, the requested allergy injections are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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 dalfampridine 10 mg tablets extended release 12 hours (Ampyra) 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. Ampyra is considered a standard therapy for treatment of patients with MS and its efficacy is supported by medical evidence. Additionally, Ampyra is a U.S. Food and Drug Administration approved therapy for patients with MS. In this case, the patient had been prescribed the medication and had a favorable response. After halting Ampyra, the patient subsequently had a decline in her walking which affected her activities of daily living. As such, the documentation as well as the medical evidence support the benefits of this medication for this patient with MS. Accordingly, dalfampridine 10 mg tablets extended release 12 hours (Ampyra) 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old female enrollee has requested Crinone 8% (progesterone gel) for the prevention of miscarriage. Findings:  Three physician reviewers found that spotting in early pregnancy is common, occurring in 25% of pregnancies (see Deutchman and colleagues). Standard therapy for this symptom involves ultrasound to confirm fetal viability and exclude ectopic or molar pregnancy (see Dighe and colleagues). There is no evidence Crinone (progesterone) therapy decreases the risk of miscarriage in this patient population. As a study by Poulose and colleagues indicates, more than 90% of patients presenting with first trimester bleeding will continue the pregnancy with the greatest risk of miscarriage present in patients with heavy bleeding, rather than just spotting. According to the American College of Obstetricians and Gynecologists (ACOG), the use of Crinone for pregnant patients is only indicated in those patients with ovarian failure or documented luteal phase insufficiency. While Clomid therapy may contribute to luteal phase dysfunction, this is not documented in the case of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for nerve testing (autonomic testing) (CPT-95923) (CPT-95924) provided. Findings:  The physician reviewer found that Autonomic testing over the years has become the gold standard for diagnosis of POTS. Arnold and colleagues indicate, The most sensitive method to detect POTS is a detailed medical history, physical examination with orthostatic vital signs or brief tilt table test, and a resting 12-lead electrocardiogram. According to Goodman, The diagnostic evaluation of a patient with suspected POTS requires a thoughtful diagnostic approach. The authors state that this clinical examination involves an assessment of pupillary responses, an evaluation for sudomotor and vasomotor signs, and an assessment for joint hypermobility. Laboratory testing helps to exclude mimics of autonomic dysfunction, recognize conditions that may exacerbate symptoms, and to identify conditions that may cause or be associated with autonomic nervous system disease. The purpose of autonomic testing is to confirm a POTS diagnosis, exclude other causes of orthostatic intolerance, and may provide for characterization of POTS into neuropathic and hyperadrenergic subtypes. The medical evidence supports the services at issue in this clinical setting. Therefore, nerve testing (autonomic testing) provided was likely to have been more beneficial for evaluation of the patients medical condition. Findings: Three out of three physician reviewers found that nerve testing (autonomic testing) (CPT-95923) (CPT-95924) provided  was not likely to have been more beneficial for the enrollee than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturn.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in neurology. All reviewers 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the brand name medication Remeron and the brand name medication Zoloft. The submitted documentation fails to demonstrate the medical necessity of the requested medications. This patients providers have opined that brand name medications are not medically necessary. The patient has made the claim that he is allergic to all generic medications. His providers have opined that there is no medical condition which would cause a patient to be allergic to all generic medications. The U.S. Food and Drug Administration (FDA) has indicated that generic medications and brand name medications have similar efficacy. The medical records do not contain progress notes which document the patients reported adverse effects. There is a lack of objective evidence in the medical records to indicate that the patient has had adverse effects from generic medications. Therefore, the brand name medication Remeron and the brand name medication Zoloft are not medically necessary for the treatmetn of this patient. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychaitry 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 58-year-old male who experienced a right radial head fracture in December 2003 as the result of a fall. The patient is status post open reduction with internal fixation. He received physical therapy from January 2004 until May 2004. In April 2004, it was noted the patients elbow flexion range of motion was 136 degrees and extension was 16 degrees. The patient is concerned his extension has regressed; he has requested authorization for an additional two months of physical therapy. The Health Plan has denied the request on the basis that additional physical therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted records indicate flexion is over 130 degrees and extension is 16 degrees. The patient is six months post surgery. Given the patients age, and the length of time since surgery, his condition is not likely to improve with additional physical therapy. The patient has had an excellent outcome; continued supervised physical therapy will not have any functional impact. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal provided for treatment of an emergency medical condition. 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 breast implant removal provided on 2/5/16 was not necessary for treatment of an emergency medical condition. Implant removal may be considered an emergency surgery in cases of documented infection or implant exposure. However, in this case, there is no mention of any concern for possible infection, severe pain that cannot be controlled with oral medication, or other medical condition that would warrant emergency surgery. In the clinical setting of ruptured silicone implants, implant removal and capsulectomies is medically indicated, however, this is not an emergency medical condition. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

A 56-year-old male enrollee has requested the medication Lyrica for treatment of his lower extremity pain and Parkinsons disease. Findings:  The physician reviewer found that the use of Lyrica is FDA approved for neuropathic pain from diabetes and post-herpetic neuralgia, but not for back and radicular leg pain from degenerative disc disease of the lumbar spine.  It is not uncommon for a physician to use a medication off label in a somewhat similar situation as the medication was initially designed for and often times, FDA drugs are approved for a specific diagnosis and then the indication for use widens over time. Given the patients excellent response to Lyrica (to the point that he was able to cancel his planned surgery) continued use of the medication is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee requested sofosbuvir (Sovaldi) 400 mg daily #30, and ribavirin 200 mg twice per day #60 for treatment of his hepatitis C.   Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), when a provider chooses to treat a patient without pegylated interferon, then the duration of the treatment is 24 weeks. In this patients case, the provider has not documented in the clinical information provided the clinical rationale for not using interferon. The treatment of hepatitis C virus therapy with triple or dual regimen is appropriate. Therefore, the requested sofosbuvir (Sovaldi) 400 mg daily #30, and ribavirin 200 mg twice per day #60 is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage of the medication Actiq. The Health Plan has denied the enrollee's request indicating that the requested medication is not medically necessary for treatment of the enrollees back and shoulder pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for psychiatric emergency services. Findings:  The physician reviewer found that the patient was not medically screened to determine if an emergency medical condition existed. There was no psychiatric admitting evaluation and therefore no screening to determine if a psychiatric medical emergency existed. He did not have any symptoms so acute that absent medical care they would place his health in serious jeopardy, cause serious impairment to bodily functions, or cause serious dysfunction of any bodily organ or part. In addition, he was not experiencing a psychiatric medical emergency in that he did not have symptoms of acute severity manifesting as danger to himself or others, or immediate inability to provide care for himself (not gravely disabled). The patient did not meet the criteria for requiring emergency medical services or psychiatric emergency services at any time, on admission to the facility on 4/28/18 or thereafter. Thus, the services provided were not provided for a psychiatric medical emergency. Final Result: The reviewer determined that the services at issue were not provided for treatment of a psychiatric emergency. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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

A 47-year-old female enrollee has requested a spinal cord stimulator (SCS) implantation for the treatment of her lower extremity pain. Findings:  Three physician reviewers found that the most common FDA approved indication for spinal cord stimulation in the United States is post-laminectomy syndrome with neuropathic pain. There are many well-designed studies documenting its efficacy in this clinical scenario. In this patients case, the use of the spinal cord stimulator was within acceptable parameters and should not be considered experimental.