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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the lower back and leg for evaluation of his low back pain with radiation across the back and to calf. Findings:  The physician reviewer found that according to the literature, routine lumbar spine imaging in patients with low back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging. The literature noted that evidence indicates that immediate, routine lumbar spine imaging in patients with low back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging. In addition, the literature reported that clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition. Thus, the requested MRI of the lower back and leg are not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedures 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: Upheld

An enrollee has requested authorization and coverage for an inpatient hospital stay.Candidates for surgical repair of pelvic organ prolapse are women with symptomatic prolapse who have failed or who have declined conservative management. Hysterectomy is often performed at the time of pelvic organ prolapse repair. Definitive management with hysterectomy, including repair of cystocele and rectocele, is done electively to improve the quality of life for these symptomatic women. This surgical procedure is performed in the surgical center with a planned period of observation anticipated to be less than 48 hours for postoperative recovery. In this case, the patient will be undergoing an elective hysterectomy with cystocele/rectocele repair for worsening pelvic organ prolapse. However, there are no unique clinical circumstances in the patients medical history that would warrant acute inpatient admission for her postoperative recovery. The patient can be expected to be safely and effectively cared for under an observational level of care. Therefore, the requested inpatient hospital stay is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee has requested high-dose chemotherapy with autologous hematopoietic stem cell transplant for the treatment of his autoimmune disease. Findings:  Three physician reviewers found that this patient has a severe, progressive autoimmune disease. He has tried and failed all standard therapies. Unmanaged, his condition will continue to worsen. There is literature support for autologous stem cell transplant as a more encouraging alternative for patients who are refractory to traditional treatments for autoimmune disease. There is no reasonable alternative at this stage.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services 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 ED services provided (CPT codes 99283 and 99053) were necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient presented with rapidly progressive throat pain. In this clinical setting, there is potential for the development of acute epiglottitis, parapharyngeal abscesses and infections, allergic laryngeal spasm which are serious, life threatening conditions that may present in this way and be rapidly progressive. It was appropriate to seek immediate medical evaluation for this symptom complex. In addition, treatment with dexamethasone steroid medication indicated that the emergency provider recognized that these symptoms had the possibility for further progression and injury to vital body parts. Therefore, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue. 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: Overturned

A 20-year-old male enrollee has requested a sleep study for evaluation of his seizure disorder. Findings:  The physician reviewer found that seizures are part of the differential diagnosis of abnormal motor behavior occurring during sleep. Optimal diagnosis of nocturnal seizures requires a polysomnogram with full electroencephalogram montage, with simultaneous video recording if possible. Additionally, there is significant evidence that there is a pathogenic link between sleep apnea and seizures (i.e., apnea can cause seizures and does exacerbate seizures). There has been a substantial amount of research done since the 1980s that provides evidence of this link. Given the patients history of nocturnal seizures, the proposed sleep study is likely to be clinically useful in this setting. As such, further evaluation with a sleep study is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for custom wheelchair with rear suspension option spinergy wheels for treatment of the enrollees spina bifida. Findings: The physician reviewer found that the request for custom wheelchair with rear suspension option spinergy wheels is medically necessary for treatment of the patients medical condition. Hurd and colleagues evaluated manual wheelchair propulsion across level ground conditions encountered during everyday life. The authors concluded that The rolling resistance of level surface terrain significantly impacts wheelchair propulsion biomechanics. Boninger and colleagues suggested using the lightest wheelchair possible to decrease the risk of injury to the wheelchair user. In this case, the requested wheelchair modifications of rear suspension option and spinergy wheels are medically necessary to decrease the risk of injury to the patients extensive spinal hardware. The patient will require further extensive spinal surgery in the form of a full spinal fusion if the implanted rods are damaged. All told, the requested equipment is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for PROPEL sinus implants utilized during sinus surgery. Findings:  The physician reviewer found that FESS, surgical outcomes can be compromised in the immediate post-operative period by scarring, adhesion formation, and early polyp recurrence. Oral and topical corticosteroid therapy are standard treatments for the maintenance of successful surgical outcomes, the management of post-operative scarring and edema, and the prevention of nasal polyp recurrence. Shen and colleagues report that clinical evidence has demonstrated the safety and efficacy of steroid-eluting sinus implants in the reduction of polyp size, symptom burden, and the need for revision sinus surgery. Hoffman and colleagues note that steroid-eluting sinus implants have been shown in clinical trials to improve postoperative outcomes after functional endoscopic sinus surgery (FESS) by delivering localized, sustained release of corticosteroids directly onto inflamed sinus tissue. The U.S. Food and Drug Administration approves the use of the PROPEL sinus implant for use in adult patients following sinus surgery to maintain patency of the frontal and maxillary sinus ostia. The FDA further notes that the device separates mucosal tissues, prevents obstruction by adhesions, and reduces edema. In this clinical setting, the safety and efficacy of the devices at issue has been established in current medical literature. Therefore, PROPEL sinus implants utilized during sinus surgery were likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the PROPEL sinus implants utilized during sinus surgery at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested devices were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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 Norco. Findings:  The physician reviewer found that based on the presented clinical records, the request for Norco is not medically necessary for treatment of the patients medical condition. In this case, the patient is requesting opioid medication for treatment of his chronic nonmalignant pain. However, there are alternative treatments available for this patient such as non-opioid medications, physical therapy, chiropractic care, acupuncture and interventional care. Also, urine drug screening was consistent with previous cannabis use. The patient has declined subsequent urine drug screening. For these reasons, the request for Norco is not medically necessary for treatment of the patients medical condition. 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 reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Sovaldi and Olysio for treatment of his hepatitis C virus genotype 1a.   Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Overall, the data supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy due to non-liver-related comorbid conditions. Consistent with the current FDA recommendation, the combination of Sovaldi and Olysio should be approved for 12 weeks in this patient. Thus, the requested 12 week course of Sovaldi and Olysio is supported as medically necessary for treatment of this patients hepatitis C virus infection.   Final Result: Three  reviewers concluded that the requested medications are medically necessary for treatment of the enrollees medical condition.  Because all three physician reviewers concluded that the requested medications are medically necessary for treatment of the enrollees medical condition, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology.   Physician reviewer number two is actively practicing and is board certified in internal medicine with sub-specialty certification in gastroenterology. Physician reviewer number three is actively practicing and is board certified in internal medicine with sub-specialty certification in gastroenterology.  All three reviewers are knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 270 sterile gauze pads per month and 270 urinary catheters per month.The requested supply of 270 catheters per month implies a catheterization frequency of at least 7 times per day and possibly more. Sterile gauze pads for an established surgical site (catheterizable stoma) or to grasp intermittent catheters would prove no safer than clean gauzes for both purposes. The patients circumstances are complicated, but increasing the frequency of catheterization to the requested frequency does not solve her underlying issues of bladder storage and her clinically incompetent catheterizable channel. At this time, there is no literature or clinical support for the requested frequency of catheterization and hence the number of catheters and sterile gauze pads that have been requested. Accordingly, the requested 270 sterile gauze pads per month are not medically necessary to treat the patients medical condition. In addition, the requested 270 urinary catheters per month are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested supplies 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 urology 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 intensity modulated radiation therapy (IMRT). Applying the recommendations from guidelines, IMRT has not been demonstrated to yield superior patient health outcomes when compared to standard whole breast radiotherapy utilizing 3D conformal radiation therapy in the treatment of this patients breast cancer. Furthermore, high quality clinical outcomes published in the medical literature and expert-consensus national guidelines. Based on the peer-reviewed medical literature and current guidelines, the patient could have been treated with hypo fractionated 3D conformal radiation therapy, which has been associated with equivalent safety and efficacy this patients clinical situation. Therefore, the IMRT was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is 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 71-year-old female enrollee has requested acute inpatient rehabilitation services for treatment of her paralysis.  Findings:  The physician reviewer found that the patient has a stable functional status. Thus, the location of physical therapy and occupational therapy has very little impact on expected outcome (Ward, et al). Recovery depends upon rate of neurological recovery. The patient has done well but continues to lack the muscle strength to push up from the seated position. Continued physical therapy and occupational therapy will maintain her current status but is unlikely to change her status in the absence of neurological recovery (Stolee, et al). At this stage of recovery, her neurological gains will be slow and more intensified therapy will not significantly change her functional outcome (Anderson, et al). All told, the requested acute inpatient rehabilitation services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old female enrollee has requested Botox injections for treatment of the enrollees chronic headaches.   Findings:  Two physician reviewers found the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. Although Botox is not considered first-line therapy for chronic migraine, there is solid evidence supporting its use in refractory cases. In this case, the patient has failed multiple first-line therapies or has a contraindication for their use, hypotension. Furthermore, the patient was noted to have pronounced benefit from a prior trial of Botox. Thus, use of Botox was and is likely to be more beneficial than other standard therapies for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee requested authorization and coverage of remicaide infusion therapy for the treatment of rheumatoid arthritis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Supartz injection series in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed arthroscopic surgery, along with turmeric, Aleve, physical therapy, and rest. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested service is medically indicated. Therefore, a Supartz injection series in the right knee 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 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.